Drinking Water & Health Quarterly – Winter/Spring 2004 – Volume 10, Issue 1

Moving Toward Better Infection Control in Healthcare Facilities

Against the backdrop of recent infectious disease outbreaks, including the international public health threat of SARS, the U.S. healthcare community has recently taken proactive steps toward learning how to effectively identify and prevent the occurrence of deadly healthcare facility infections.

Health care associated infections constitute a significant safety risk for individuals receiving care in a variety of settings. The Centers for Disease Control and Prevention (CDC) estimates that two million people acquire an infection each year while being treated in hospitals for other illnesses or injuries, and that 90,000 people die as a result.

Newly published standards from the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), as well as CDC Guidelines, bring new focus and attention to preventing these infections.

New Standards for a New Approach

In November 2003, an expert panel of the Joint Commission released their revised standards for infection control in healthcare facilities. The JCAHO 2005 Infection Control Standards address the areas of ambulatory care, behavioral healthcare, home care, hospital laboratory and long-term care organizations. The revised standards are designed to raise awareness that health care associated infections are a national concern that can be acquired within any care, treatment or service setting. Therefore, prevention represents one of the major safety initiatives that a health care organization can undertake.

The 20-member JCAHO panel consisted of infection control practitioners, hospital epidemiologists, physicians, nurses, risk managers and healthcare professionals who were charged with both recommending enhancements to standard practices and offering insights into how the Joint Commission will better ensure that accredited organizations are in compliance with approved infection control standards.

The approved JCAHO panel standards will take effect in January 2005. A pre-publication overview of the initiative can be found on the JCAHO website at:
http://www.jcaho.org/accredited+organizations/patient+safety/infection+control/ic+index.htm

The JCAHO panel’s revised standards focus on development and implementation of procedures to prevent and control infections. The approved standards require organizations to:

  • Incorporate an infection control program as a major component of safety performance improvement programs
  • Perform an ongoing assessment to identify the risks for the acquisition and transmission of infectious agents
  • Use an epidemiological approach, including collecting and interpreting data
  • Implement infection prevention and control processes
  • Educate and collaborate with leaders across the organization to design and implement infection control programs

Two new developing healthcare issues have been identified since the JCAHO standards were outlined. Requirements for addressing emerging antimicrobial resistance, and managing epidemics and emerging pathogens are currently being reviewed by accreditation organizations.

The revised standards are designed to assist in the identification and reduction of risks that can lead to acquiring and transmitting infection among employees, physicians and visitors at medical healthcare facilities. The standards cover both direct patient care and those used to support patient care. The JCAHO standards will require healthcare organizations to work with local, state and federal agencies to prevent and control the introduction of infectious diseases.

CDC Guidelines Promoted to Reduce Risk of Infection

The CDC has also issued its own recommendations tool, Guidelines for Environmental Infection Control in Health Care Facilities. These guidelines are a four-part report available on the CDC’s Division of Healthcare Quality Promotion website < http://www.cdc.gov/ncidod/hip/default.htm>.

In general, the report recommends:

  • Adherence to proper use of disinfectants, proper maintenance of medical equipment that use water
  • Water-quality standards for hemodialysis, and proper ventilation standards for specialized care environments (airborne infection isolation, protective environment, and operating rooms)
  • Prompt management of water intrusion into facility structural elements to minimize healthcare-associated infection risks and reduce the frequency of outbreaks
  • Conduct routine environmental sampling only when it is directed by epidemiologic principles and the results can be applied directly to infection control decisions

The CDC also has also released guidelines for hand washing in healthcare facilities. The general recommendations are as follows:

1) Wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water when they are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids
2)
If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands
3)
Hands should be cleaned after contact with a patient’s intact skin, contact with environmental surfaces in the immediate vicinity of patients and after glove removal

These CDC reports these general recommendations are promoted to minimize the risk of transmission of microorganisms to patients, minimize the potential risk of healthcare worker infection caused by organisms acquired from the patient, and reduce the mortality rates and healthcare costs associated with healthcare-associated infections.

SARS Case Study Sheds Light

In the wake of the re-emergence of SARS cases, recent policy reviews and recommendations have been offered within the healthcare community regarding infection control procedures. In the upcoming March 2004 issue of the CDC’s Emerging Infectious Diseases Journal, the article, “SARS Transmission and Hospital Containment” reviews the lessons learned from the SARS outbreak in Singapore in March 2003. The recommendations provide insight into how healthcare facilities may analyze a potential outbreak situation and approach its policy on infectious disease management and spread prevention.

The study presents insight into the alternate containment strategies that were used by three different hospitals in Singapore in their efforts to contain the infection in March 2003. The strategies employed were:

1) Close the entire hospital

2) Remove all potentially infected patients to a dedicated SARS hospital

3) Manage exposed persons in place

By evaluating how the contrasting strategies in these three hospitals affected the spread of the virus, a best practices evaluation was developed supporting the position that circumstances of the individual detection will dictate the appropriate healthcare facility response to the outbreak. The journal article findings conclude that SARS is managed most effectively in early detection circumstances by 1) removing all exposed people to a designated location, or 2) isolating them and managing them in place. In late detection scenarios, however, a hospital may be more successful in disease-spread management by closing its doors to contain the spread of the disease.

With these strategies outlined, the best practices containment discipline recommendations included the following:

  • Obtain contact history – Review the patient’s contact history for contact with other SARS patients. Also review other areas in the hospital where they may have stayed. This should be done within 48 hours. All contacts should be quarantined or kept under medical surveillance.
  • Monitor Healthcare Workers for Fever – Monitor and record the temperatures of all hospital staff three times a day. Healthcare workers with a temperature greater than 37.5°C should not be allowed to work and those with a fever for more than three days, or occurring as part of a cluster of cases, should be isolated. Also, when more than two staff members of patients in a clinical area are febrile, epidemiologic investigation should be initiated.
  • Wear Personal Protective Equipment – Strict adherence to the use of personal protective equipment (N95 masks, gloves and gowns) can mitigate the spread of an outbreak
  • Maintain a Visitor Log and Limit Visitors – In Singapore, at least 21 cases resulted from spread by hospital visitors to family and community contacts. A “no visitor” policy in all public hospitals was implemented in Singapore.
  • Create a Hospital Preparedness Plan – Reviewing and updating response plans, as well as educating employees about the plan may help limit the spread of an illness such as SARS

An “ahead of publication” release of the Emerging Infectious Diseases Journal article can be found on the CDC website at http://www.cdc.gov/ncidod/EID/vol10no3/03-0650.htm.

Sea Sick — Infection Outbreaks Challenge the Cruise Ship Experience

For decades, cruise ships have been a popular vacation destination for those seeking a reprieve from the wintertime blues. Over ten million people traveled on cruise ships in 2000 and that number is expected to double by 2010. But some recent vacationers have found themselves wishing they never said, “Bon Voyage.”

In 2002, a wave of gastroenteritis outbreaks occurred aboard several international cruise ships, turning the sojourns of many sea-bound, sun-revelers into shortened trips they would most likely want to forget. As recently as February 2004, more than 300 Carnival Cruise Line ship passengers were stricken with the stomach malady while aboard the Celebration luxury liner while on a Valentine’s cruise in Mexico. Unfortunately, such outbreaks are not a surprise to the industry. According to a 2003 World Health Organization (WHO) study, “Emerging Issues in Water and Infectious Disease,” since 1970 over 100 disease outbreaks associated with cruise ships have been documented. The WHO considers this figure low, because many such illnesses go unreported.

Virus on the High Seas

Among the several illnesses and maladies that can affect a cruise ship passenger, food and water borne viral gastrointestinal illness is the most common culprit. Symptoms include nausea, vomiting, diarrhea and in some instances, severe stomach cramping. Transmitted person-to-person (meaning it can be transferred both through human contact and through contact with food, water or surfaces that are contaminated with illness-causing germs), an infectious virus has the ability to take on outbreak proportions quickly in the closed environment of a cruise ship. With the complicating factor that these viruses can remain active on objects and surfaces for periods of up to 14 days, the likelihood of human exposure to the virus is greatly increased, facilitating its spread and increasing the probability of infection outbreaks.

The most common type of virus linked to gastrointestinal illness is the Norwalk-like Virus (NLV) or norovirus, which gained notoriety from a 1968 outbreak in Norwalk, Ohio. The term norovirus was recently approved as the official name for this group of viruses. Several other names have been used for noroviruses, including, caliciviruses (from its origin in the virus family Caliciviridae) and “small round structured viruses”. Noroviruses are the leading cause of gastrointestinal illness with an estimated 23 million cases a year, according to the U.S. Centers for Disease Control & Prevention (CDC).

Typically, shipboard norovirus spawns from poor sanitation conditions, including contaminated bunkered water, inadequate disinfection of potable water, potable water contaminated by sewage on ship, deficiencies in food handling, and poor food preparation and cooking methods. Significantly, there is no vaccine to prevent contracting norovirus. Antibiotics will only work to fight bacterial infection, not to treat viral outbreaks.

From July 1997 to June 2000 there were 232 outbreaks of norovirus illness reported to the CDC of which, 57% were foodborne, 16% were due to person-to-person spread, and 3% were waterborne. In 23% of outbreaks, the cause of transmission was not determined. According to the CDC common settings for outbreaks include restaurants and catered meals (36%), nursing homes (23%), schools (13%), and vacation settings or cruise ships (10%). The CDC estimates that as many as half of all food-related outbreaks of illness may be caused by norovirus. In many of these cases, food handlers experiencing a viral illness were identified as the likely carriers and transmitters of the disease.

Complicating matters, it has been discovered that norovirus is a nimble and difficult virus to control. Recent research conducted by the UK Health Protection Agency suggested that a new variant of the virus was to blame for the spate of 2002 cruise ship outbreaks. Through data collection, the Agency discovered a specific and identifiable mutation in one of its genes.

Nothing New Under the Sun

While recent events have focused media attention as never before on the public health conditions in the cruise ship industry, the story of shipboard illness is not a new tale. In an effort to prevent contamination aboard luxury cruise ships in the early 1970’s, the CDC established the Vessel Sanitation Program (VSP). Under the VSP, over 140 cruise ships are subjected to unannounced, twice-yearly inspections where the ship must score 86 or above on a 100-point scale. The inspections are conducted in U.S. ports only, and are overseen by VSP environmental health officers. Inspectors focus on the ship’s water supply, spas and pools, food, employee hygiene, ship cleanliness and a review of the ship environmental training programs. The VSP also monitors reports of diarrheal illness on each ship.

If an outbreak of gastrointestinal illness occurs, the VSP works with other infectious disease programs at the CDC to initiate an investigation. An outbreak is defined as having 3% or more of either passengers or crew reported with illness. Cruise vessels sailing to U.S. ports are required to notify the CDC of every case of gastrointestinal illness reported to the ships’ medical staff for each cruise. This summary report must be filed 24 hours prior to arrival at a U.S. port. If the number of ill passengers or crew reaches 2% during the cruise, the vessel is required to file a special alert report informing health authorities of the abnormality. The CDC closely monitors these illness reports on a daily basis.

Back-to-Basics Is the Key to Prevention

Whether shipboard or at home, preventive steps are considered to be the best means of avoiding contracting norovirus infection or similar viral illness. By practicing sound and sensible personal hygiene, individuals can help reduce the chances of contracting the virus and spreading it. The CDC’s recommended preventive measures include:

  • Frequently wash your hands (especially after toilet visits)
  • Carefully rinse fruits and vegetables
  • Thoroughly clean and disinfect contaminated surfaces with a chlorine bleach-based cleaner immediately after an episode of illness
  • Immediately remove and wash clothing or linens that may be contaminated with the virus after an episode of illness

Prevention of food-borne norovirus disease is based on safe storage and handling habits for both food and water. While noroviruses are relatively resistant to environmental conditions (they are able to survive freezing, temperatures as high as 60°C, and have even been associated with illness after being steamed in shellfish), relatively simple, common sense measures can limit much of their impact. Correct handling of cold foods, frequent hand washing, and not handling food when ill are suggested as habits that may substantially reduce food-borne transmission of norovirus.

Additionally, many local and state health departments are requiring that food handlers and food preparers who have suffered recent bouts of gastroenteritis not work until 2 or 3 days after they recover from their illness. Significantly, since the virus continues to be present in human waste for as long as two to three weeks after the person feels better, strict hand washing after using the bathroom and before handling food items is considered critical to the prevention of a viral spread. Recommendations include the proviso that food handlers who have experiences illness can be given alternate duties to direct contact with consumables, such as running the cash register or hostessing.

A Recent Wave

The year 2002 was a wake up call for a world largely unfamiliar with noroviruses. There were 25 reported outbreaks of the Norwalk-like virus on cruise ships, leaving a total of 2,648 passengers ill on their vacation get-aways. Major cruise lines such as Norwegian, Royal Caribbean, Carnival, Holland America and Disney were hit 19 times by outbreaks of gastrointestinal illness, all of which were attributed to norovirus.

In October and November 2002, Holland America’s Amsterdam cruise ship experienced four successive cruises in which norovirus struck members of both the crew and passengers. A total of 524 people (passengers and crew) had become ill — roughly 25% of the ship population for the total of the four cruises. The first cruise, which ran from Oct. 1st – 22nd, had 196 passengers and a dozen crew contract the Norwalk like virus. The ship was disinfected, scrubbed and cleared to embark on its next voyage. The following cruise (Oct. 22nd – Nov. 1st) had an outbreak as well, with 41 passengers and 8 crewmembers becoming ill from Norwalk-like viral infection. The result was that Holland America was drowning in a sea of bad publicity, as the cruise line was routinely portrayed as an unhealthy breeding ground for the virus.

Prior to boarding on its Nov. 1st -11th cruise, the staff of Holland America distributed a printed notice to passengers, informing them that the previous cruise had been disinfected. Yet despite adhering to CDC’s disinfection and sanitation measures, the outbreaks continued with 163 passengers and 18 crewmembers confirmed ill. It was reported that the common greeting among passengers was to rub elbows to avoid direct hand-to-hand contact.

Despite three successive cruises with an outbreak, Holland America’s Amsterdam set out Nov. 11th on another cruise. Yet again an outbreak developed, with 36 people offloaded for symptoms associated with Norwalk. Finally on November 21st, the vessel was temporarily taken out of service for aggressive cleaning, isolation of affected crew and other control methods. The Amsterdam was back on the seas December 1st, reporting on a daily basis to the CDC.

An Ongoing Battle

While the cruise ship industry in total reports that it is follows strict regulations designed to prevent viral contamination and public health challenges, norovirus outbreaks have continued to occur. In December 2002, Carnival Cruise Lines suffered back-to-back outbreaks on its 7-day Caribbean cruises bound for New Orleans. That same month Royal Caribbean also reported that two of its cruise ships had Norwalk-like virus outbreaks.

The CDC reported in its 2002 year-end review that the cruise ship outbreaks of that year demonstrated just how easily norovirus is transmitted from person to person in a closed environment. According the CDC, both the event of outbreaks on consecutive cruises populated by new passenger and the resurgence of outbreaks caused by the same virus strains during previous cruises on the same ship (or on different ships of the same company), suggests that environmental contamination and infected crew members can serve as reservoirs of infection for passengers. It also offered possible explanations for the increase in infection rates, positing that the 2002 outbreaks might have reflected either an actual increase in norovirus outbreaks, or could have been attributable to improved surveillance with an electronic reporting format implemented January 1, 2001. New bio-surveillance systems and the increased application of sensitive molecular assays capture data on cases of illness reported to the ship’s infirmary or to designated staff on board the ship.

Emphasizing basic food and water sanitation measures, the CDC recommended control efforts that should include thorough and prompt disinfection of ships during cruises, and isolation of ill crew members and passengers (if possible) for 72 hours after clinical recovery. Rapid implementation of control measures at the first sign of a suspected gastrointestinal outbreak is considered to be critical in preventing additional cases of illness aboard ship. Chlorine-based cleaning solutions are recommended for disinfection. When routine disinfection measures are unsuccessful in interrupting the viral spread, the CDC recommends more extensive disinfection procedures, as well implementation of a waiting period – a sustained time without passengers aboard a ship to facilitate final eradication of the virus.

With no single, easy-to-implement solution on-tap, conventional public health regimens are still considered to be the best method of halting infection outbreaks in the cruise ship industry. A back-to-basics approach that includes common sense personal hygiene routines and safe, effective disinfection practices are viewed as the best defense against a public health foe that continues to ride the waves.

Water in the Balance – A Boiling Crisis for the Nation’s Water Supply

For the millions who populate the sweeping area of geography from Detroit, Michigan to Toronto, Ontario to New York, New York, the moment electrical power ceased on August 14, 2003 will not soon be forgotten. Failures in key elements of the electric grid infrastructure triggered unprecedented power outages, paralyzing large segments of population on both sides of the U.S. – Canadian border. An estimated 50 million people were suddenly without the most basic functions of daily life during what came to be known as the Northeastern Blackout of 2003.

While the blackout was largely an energy sector story highlighting the vulnerabilities of a major North American power grid, it also became a tale of crisis for the water systems in the affected areas. The interconnectedness and fragility of public service infrastructures was clear, amplifying what drinking water utilities across the country have long recognized as a significant risk to the nation. Coupled with the events of September 11, 2001, the nation’s aging drinking water systems were revealed as subject to major disruption, threatening the availability of safe drinking water, the security of public waters and the delivery of vital services dependent on water supplies.

Legislation passed in 2002 requires water utilities to assess their vulnerabilities to terrorist attacks and to develop emergency response plans. These steps will help water systems respond to other types of emergencies, including blackouts. EPA established a grant program to assist utilities in conducting assessments. However, additional funds will be needed to implement the needed security upgrades. Furthermore, this much needed system overhaul will take years. Still, with water in the balance, the importance of immediate emergency water treatment responses have never been more necessary. Boil water alerts and chlorine treatments remain the most practical, viable methods of protecting water purity, preserving public health safety and providing a safe and healthy alternative water supply in crisis situations.

Troubled Waters

Among the several public health hazards that were revealed by the massive loss of power, including medical equipment malfunction, loss of air circulation and cooling functions, and impaired emergency response communications, was the central and potentially long-term effect of lost technology that governs and regulates wide-ranging portions of the public water systems.

In Cleveland, all four of the city’s water pumping stations that move water uphill from Lake Erie to 1.5 million customers went down at once, leaving residents without water. Since only one station is needed to pump water to all customers, officials never anticipated that all four pumps would go down simultaneously. While Detroit’s water system had backup generators in place at some water utility plants, the power generated was not enough to keep a suitable amount of pressure in the pipes, leaving 4.3 million residents of Macomb County without water service during the entirety of the blackout.

Despite the inconveniences and challenges of water service interruptions, however, are fears of a more lasting effect. Namely, disease introduction through lost water service. When power generation and distribution ceases in a blackout event, the electricity powering the pumps that push water through a city’s water system can go out as well. With a resulting drop in pipe pressure, the system is open to a potential public health crisis in the form of bacteria entering the water supply. In this circumstance, drinking water can become contaminated and a normally trusted water system becomes the potential breeding ground for waterborne infection and disease.

Boiling and Chlorination Are the Best Defense

During the blackout of August 2003, water customers in Cleveland and Detroit were immediately placed under a three-day boil-water advisory. Detroit took the extra step of adding extra chlorine to its municipal water supply to combat the introduction of illness-causing bacteria. In addition, Macomb County officials ordered the area’s 2,300 restaurants to shut down until the water was confirmed as not contaminated. Local water departments did not lift the boil-water alert until two water sample tests came back negative for contamination within the course of a 24-hour period.

According to the EPA, there are two essential methods to purify water for cooking and drinking depending on the circumstance. One method is boiling – the preferred method for making household water safe. Boiling water for one minute will kill any disease-causing microorganisms in the water and purify it for use as drinking or cooking water.

The second method is treating the water with chlorine. Common household bleach contains a chlorine compound that will disinfect water. The procedure to be followed is usually written on the label. When the necessary procedure is not given, however, the EPA recommends finding the percentage of available chlorine from the container label (regular household bleach is typically 5.25%, “ultra” bleach is typically 6.5%) and using the following general guide:

Available Chlorine
Drops per Quart of Clear Water
1%
10
4-6%
2
7-10%
1

EPA advises that the chlorine-treated water should be mixed thoroughly and allowed to stand, preferably covered, for 30 minutes. The water will have a slight chlorine odor. If not, the dosage should be repeated and the mixture allowed to stand for an additional 15 minutes. If the treated water has too strong a chlorine taste, it can be lessened by allowing the water to stand exposed to the air for a few hours or by pouring it from one clean container to another several times.

While safe and effective, chlorine treatment it generally recommended only when boiling is not a practical option.

Government Agencies Address the Issue

The immediate effects of the Northeast Blackout of 2003 on citywide and regional water systems provided a definitive window into a serious problem that federal officials had recognized since the days following September 11, 2001. Proactive protective measures were needed to shore up lagging security and infrastructure maintenance issues that weakened local, regional and national water supplies. Under authority of the Presidential Decision Directive 63 and the Bioterrorism Response Act of 2002, the EPA took on the lead role for drinking water system security, initiating a program of funding allocation and information distribution for the enhancement of water system security. EPA programming recommendations also include sourcing additional funds to support security upgrades, in addition to the current $100 million Congressional appropriation for drinking water systems vulnerability assessment and terrorist response plan development.

In October 2003, the U.S. Government Accounting Office (GAO) released a report, Drinking Water: Experts’ Views on How Future Federal Funding Can Best Be Spent to Improve Security to the Senate Committee on the Environment and Public Works. The report was based on a survey of 43 nationally recognized experts to ascertain how federal funding could most positively affect water system security improvement. The GAO report concluded that two major vulnerabilities exist in current water security policy.

1) Utilities lack the necessary information to identify their most serious threats
2)
Utilities do not possess adequate back up systems. A reported lack of redundancy in the most basic public utility services leaves the normal functions of many population centers vulnerable to a single catastrophic event.

The report’s majority recommendation suggested that federal grants be administered directly to the states, rather than the Drinking Water State Revolving Fund. The GAO study identified three areas where federal support is critical:

  • Physical and technological upgrades
  • Education and training
  • Strengthen key relationships

Under the Bioterrorism Response Act, the EPA is required to order all community public water systems serving 3,300 people or more to conduct vulnerability assessments and prepare or revise an existing emergency response plan that incorporated the results of the vulnerability assessment. These required actions are designed for institution by June 30, 2004. The EPA has up to six months from the filing date of the vulnerability assessment to certify its contents.

To date, the completed vulnerability assessments have indicated that significant additional funds are necessary to support the implementation of security upgrades. Although Congress allocated more than $100 million in initial funding through fiscal year 2004, it is unlikely that these funds will do little more than help utilities plan for upgrading drinking water security. A large-scale budget will be required to implement the needed security upgrades considered essential to protect the nation’s drinking water systems.

Still Unprepared

Since the GAO submitted its report to Congress in October 2003, there has been little initiative towards appropriating more money to remedy the current challenges to national drinking water systems. Both the traumatic events of terrorism that initially invigorated the process and the future water crisis that the 2003 Northeast Blackout revealed on the national stage have lost a good deal of their momentum to motivate water security issues as a public issue of interest.

However, as the Northeast Blackout proved, events will not wait for decisions to be made. As we learned, an unanticipated event such as those of August 2003 can jeopardize the safety of the public water supply in an instant, and tilt life’s ordinary activities toward circumstances the nation is not yet prepared to address or handle.

Winter/Spring 2004 Washington Update

GAO Finds Bioterror Protection Gaps

According to a recent Congressional investigation, while many U.S. states have improved their abilities to respond to public health crises, no state is fully prepared to respond to a bioterrorism threat or major public health-related disaster.

In her February 12th testimony provided to the House Government Reform Committee, U.S. General Accounting Office (GAO) Director of Healthcare and Public Health Issues, Janet Heinrich identified several issues of coordination, detection, and planning that do not currently meet established preparedness requirements. Areas outlined for improvement include outbreak detection capabilities, links between public health and animal surveillance systems, public communications capacity, and completed flu pandemic response plans.

The GAO reported that by August 30, 2004, the U.S. Centers for Disease Control & Prevention (CDC) will have distributed $870 million for state bioterrorism preparedness. The U.S. Health Resources and Services Administration (HRSA) will have provided $498 million by that same date.

The GAO report Public Health Preparedness can be found at:
http://www.gao.gov/new.items/d04458t.pdf

Grumbles Nominated to Head EPA Water Office

On March 3rd, President Bush nominated Benjamin Grumbles to be the Assistant Administrator for the U.S. Environmental Protection Agency’s (EPA) Office of Water. Grumbles served as the top aide for former AA Tracey Meehan, and was named as Acting AA after Meehan resigned from EPA in December 2003.

Before arriving at EPA, Grumbles had been Deputy Chief of Staff and Environmental Counsel for the House Science Committee since February 2001. He previously served as Senior Counsel for the House Water Resources and Environment Subcommittee of the Transportation and Infrastructure Committee.

Grumbles is an adjunct professor of law at the George Washington University Law School, and a member of the faculty advisory board of the Environmental Law and Policy Program at the USDA/Graduate School.

Acheson Named Director of Food Safety and Security

On February 2, 2004, David W.K. Acheson, M.D. was appointed Director of the U.S. Food and Drug Administration’s (FDA) Food Safety and Security Staff in the Center for Food Safety and Applied Nutrition (CFSAN). In addition to providing leadership across a wide range of FDA food safety and security issues, he will also maintain his position as Chief Medical Officer for CFSAN, continuing his oversight role on all medical and clinical aspects of food safety and security issues under the FDA’s authority.

Acheson is internationally recognized for his public health expertise in food safety and his research work in infectious diseases.

The FDA press release announcement can be found at:
http://www.fda.gov/bbs/topics/NEWS/2004/NEW01013.html

EPA Releases Planning Tool for Water Security

In late December, the U.S. Environmental Protection Agency (EPA) released a package of interim guidance documents to help U.S. water utilities plan for and respond to intentional drinking water contamination.

The Response Protocol Toolbox (RPTB) was designed by EPA for integration into individual emergency response planning activities to effectively manage a threat to U.S. water supplies. Information contained in the RPTB was developed to assist in the revision of a utility’s emergency response plan (ERP), particularly for contamination threats. However, it is noted that there is currently no regulatory requirement to use the RPTB in the revision of a utility’s ERP.

The EPA produced the RPTB in conjunction with a number of U.S. drinking water utilities, in particular the Metropolitan Water District of Southern California.

A complete copy of the RPTB is available at:
http://www.epa.gov/safewater/security/pdfs/guide_response_overview.pdf

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