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Water is essential to life and comprises 60% to 70% of body weight.
Children drink more water per body weight than adults. While the United
States has made great efforts to provide safe and healthy water, not all
drinking water is contaminant-free. Children, because of their special
physiologic vulnerabilities and increased consumption of water, may be
particularly sensitive to contaminants found in their drinking water.
Contaminants may be microbial (virus, bacteria, protozoa), chemical, or
radiologic. Nurses need to be aware of the quality of their patients' and
community's drinking water and counsel those patients who may be more
vulnerable to the contaminants in their water.
Millions of pounds of potentially hazardous industrial and agricultural
chemicals are released into the environment each year in the United States.
Some of the releases are intentional and some are accidental. Our drinking
water, which is derived either from surface waters or from underground
sources, are vulnerable to contamination from the pollutant releases,
including agricultural and household chemicals, industrial waste, and
uncontrolled releases from leaking underground storage tanks and landfills.[34]
Preventing source-water contamination should be incorporated as a community
education concern.
In addition to chemical contaminants, pathogenic microbes account for an
estimated 900,000 waterborne infections annually.[35] The majority of waterborne disease incidence may be
underestimated because not all outbreaks are recognized, investigated, or
reported. Children exposed to microbial contaminants in drinking water may
experience a range of gastrointestinal symptoms depending on their immune
status and virulence of the microbe. Symptoms range from mild gastric
distress to explosive diarrhea. Several microbial contaminants cause more
than gastrointestinal symptoms. Exposure to the Coxsackie and ECHO viruses
can lead to meningitis and encephalitis. In 1999, an outbreak of E coli
0157:H7 from contaminated drinking water led to 9 deaths in New York from
toxic hemolytic uremic syndrome.
Chemical contaminants of particular concern for children include
pesticides, heavy metals, nitrates, and disinfection by-products. Infants
under the age of 6 months who are exposed to elevated levels of nitrites in
drinking water (due to contamination from fertilizer use or sewage runoff)
are at risk for developing "blue baby syndrome" (methemoglobinemia), a rare
but life-threatening illness. Nurses, as primary health providers in the
community, must be able to field questions about water quality and guide
vulnerable populations to informed decisions.
The introduction of disinfectants to the drinking water supply was one of
the greatest public health successes of the 20th century. Public drinking
water is often disinfected by the addition of chlorine to the water during
the treatment process. Although chlorine is effective in controlling many
microorganisms, it forms organic chlorine compounds, referred to as
disinfection byproducts, when it reacts with organic matter found in water
distribution pipes. Epidemiologic studies indicate that there may be an
increased risk of miscarriage in women and developmental effects to the
fetuses of pregnant women exposed to high levels of these by-products.[36-38]
Although lead paint and dust are the primary sources of exposure to lead,
lead in drinking water can contribute up to 20% of this amount. Lead can
leach out of household plumbing (lead pipes and lead solder) or from older
public water distribution pipes made of lead. In addition, boiling water for
more than 1 minute may raise the concentration of lead and other heavy
metals present in the water.
If lead is found in drinking water there are several options that should
be considered:
-
First, have blood lead
level tests performed on any children living in the home. Attempt to
identify and eliminate the source;
-
Do not use water
containing lead for mixing a baby's formula;
-
Consider a water
treatment device or an alternative drinking water source;
-
Reverse osmosis treatment
devices will remove approximately 85% of the lead; distillation systems
can remove about 99%. If these systems are used, then all water used for
drinking or cooking must come from the treated faucet (See Related
Resources for Lead Distillation Systems);
-
Replace lead pipes and
solder;
-
If it is not feasible to
remedy or if a temporary solution is needed, then flushing the water
system before using the water for drinking or cooking may be an option. If
the water from a particular faucet has not been used for several hours,
the cold-water tap should be run until it becomes as cold as it will get.
Each faucet should be flushed before using. This may not be an effective
method in high-rise buildings; and
-
Avoid cooking with or consuming water from hot
water taps because hot water dissolves lead more readily than cold.
A 1996 Amendment to the Safe Drinking Water Act allows consumers and
their healthcare providers to have access to information concerning the
quality of their drinking water. This Amendment requires public water system
providers to produce and make available to consumers a Right to Know
or Consumer Confidence Report (CCR). These reports are issued
annually and must provide information on how to contact the water provider;
the source of drinking water (river, reservoir, aquifer); any contaminants
detected and their health effects; and compliance with federal drinking
water standards. If people have not received their reports, they can call
their water company or talk with their landlord to receive a copy. The
reports include a recommendation for people with compromised immune systems
to consult with their healthcare provider regarding appropriate precautions
to take to avoid infection in the event of microbial contamination.
Therefore, it is important to be informed about drinking water and who is
more susceptible to microbial illness. The EPA has a Web site where many
local CCRs can be found (see Related Resources for EPA Safe Water). A water
supplier must notify its customers by newspaper, mail, radio, TV, or
hand-delivery if water does not meet EPA or state standards or if there is a
waterborne disease.
Largest Waterborne E coli O157:H7 Outbreak in United States
History
In September 1999, 3-year-old Rachel Aldrich died after being infected
with the toxic E coli O157:H7 strain at a New York county fair.
Hundreds of others, including Rachel's sister, Kaylea, became ill as well.
The New York Department of Health identified 71 people who were hospitalized
during the outbreak. Of these, 14 developed hemolytic uremic syndrome, a
severe complication of E coli O157:H7 infection that can lead to
kidney failure. An investigation by epidemiologists identified 781 persons
with confirmed or suspected illness (persons who developed symptoms) related
to this outbreak. Of these, 127 cases of E coli and 45 cases of
Campylobacter were confirmed by culture. (See Related Resources for
International Bottled Water Association.)
Alternative Sources of Drinking Water
When a water source is considered unsafe because of a chemical,
microbial, or radionuclide contamination, or because an individual is
considered too vulnerable to drink tap water, tap water should be avoided.
Alternatives include boiled water, bottled water, and treated or filtered
water.
Boiled water. Most harmful microbes found in water will be killed
if water is allowed to reach a full rolling boil for 1 minute. However,
boiling water for more than 1 minute may concentrate some chemicals (such as
lead, arsenic, and nitrates) and may cause some chemical contaminants to be
released in the steam where they then can be inhaled.
Bottled water. More than half of all Americans drink bottled
water; about a third of the public consumes it regularly. The National
Resource Defense Council [39]
completed a 4-year study to evaluate the quality of bottled water. They
found that bottled water regulations are inadequate to assure consumers of
safety. At least a third of the bottled water tested violated a state
standard or guideline for microbials. The FDA is responsible for good
manufacturing practices for bottled water; however, it does not have
jurisdiction over intrastate commerce of bottled water, which exempts
roughly 60% to 70% of bottled water from FDA regulation. In addition, FDA
regulations do not apply to carbonated water. The following organizations
can provide information on bottled water:
-
NSF International
(877-8-NSF-HELP)
-
International Bottled Water Association (see
Related Resources)
Water filters. There are a variety of water treatment units on the
market. No one filter removes all sources of contamination; therefore, it is
important to identify the contaminant(s) of concern before recommending or
investing in a filtration device for the home. For help in picking a unit,
contact either of the independent nonprofit organizations listed below.
(Water treatment units certified by these organizations will indicate
certification on their packaging labels.)
-
NSF International
(877-8-NSF-HELP) tests and certifies home water treatment units
-
Water Quality Association
(630-505-0160; see Related Resources for Web site) classifies units
according to the contaminants they remove and also lists units that have
earned its approval.
-
Underwriters Laboratory (see Related Resources
for Web site) also certifies some home water treatment units.
Tap Water Testing
Although public water utilities are required to test for regulated
contaminants and report the results, there may be instances when consumers
may want additional information. For example, consumers may want to check
for lead in the water. Water utilities are not required to check the lead
level at each end point. In addition, most states have some regulations
regarding the water testing of new wells; however, there are seldom
requirements for periodic retesting. Private wells are not regulated by the
EPA as public utilities are, although EPA does recommend that private wells
be tested annually.
The right to know statutes do not apply to personal wells.
Therefore, consumers with private wells should have them checked annually
for bacteria and some chemical contaminants, such as nitrates. Information
for private well owners about how to protect a private water supply, as well
as links to a list of state-certified drinking water laboratories, can be
found in Related Resources for EPA, Info on Private Wells. In addition, most
state health departments can provide a list of state-certified independent
water testing laboratories. Prices for water testing vary according to the
type and number of contaminants being detected.
NSF International
NSF International is an organization that tests and verifies that
products they certify meet all of the requirements of specified standards
and that manufacturers' claims are true. NSF does not recommend, rate, or
compare products. An NSF mark indicates assurances that the product will
perform as claimed. NSF will issue certification to water bottlers that meet
the basic FDA requirements. If the product meets the NSF standards, the
bottled water label should indicate the certification. In addition, NSF will
issue certifications for water treatment devices if they meet NSF standards.
More information about this service can be found at the NSF Web site (see
Related Resources).
Copyright American Nursing Association
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