Water Crisis Case Study



Case Study: City Water Crisis

PARTICIPANT VERSION

Learning Objectives

• Describe triggers for activating the Incident Command System

• Describe public health laws related to restaurant closure

• List the basic tenets of effective risk communication

• Identify and correct common misconceptions about risk communication

Instructions

Read each update aloud and, as a team, discuss the questions that follow.

Time Allotted: 1.5 hours

Background Materials

The following trainings, found at the North Carolina Center for Public Health Preparedness Training Web Site (), are recommended for Epi Team members without prior outbreak investigation experience. They can be viewed prior to completing the case study.

1. Risk Communication

2. Incident Command Systems for Public Health

3. Public Health Agency Emergency Response Plans Part 1

Resources

North Carolina Rules Governing the Sanitation of Food Service Establishments ()

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Question 1: Would your health department activate its Incident Command System (ICS) in this situation? Why or why not?

Group Activity

As a team, describe the structure of the Incident Command System in your health department. Choose one person to draw the ICS structure on a flip chart or white board, including the title for each position. Then each team member should describe his or her role in the ICS structure in this scenario.

Question 2: What actions should your health department take in response to the report of contamination in the water system?

Question 3: What are your public health concerns at this point?

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Question 4: What do you recommend for fast food restaurants that cannot boil water on-site?

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Question 5: Why is water pressure important for restaurants?

Question 6: There are many other agencies and organizations besides restaurants that need sufficient water pressure to operate. What are some other agencies that the environmental health specialists and other Epi Team members would be contacting in this situation?

Group Activity

The health director is concerned about how the lack of water pressure will affect institutional settings such as long term care facilities and correctional facilities. Choose either long-term care facilities or correctional facilities and describe what methods of communication the Epi Team will use to contact the facilities. Then, create a short message about the water contamination problem and appropriate actions to prevent waterborne disease transmission and other adverse effects.

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Question 7: Does the health director have the legal authority to order restaurants to close? If so, please describe this authority.

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Group Brainstorm

Because of existing relationships between county agencies (e.g. emergency management, public health, board of commissioners), the county found a timely and legal way to order restaurant closure. However, enforcing this ordinance will depend upon the relationship between the local health department and the business community.

Choose one person from your Epi Team to write answers on a flip chart. Then discuss the following question:

What can your health department do during non-emergency situations to develop positive relationships with restaurants and other members of the business community?

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Question 8: Before you send health department staff to test water pressure in restaurants, what practical issues do you need to consider? Think about how these issues are addressed within the Incident Command System.

Group Activity

You are almost ready to begin water pressure testing. First, you need to develop a plan for communicating with restaurant owners. You expect that some restaurant owners will be receptive to public health recommendations and requirements, while others may resent what they perceive as government interference. Choose one group member to be a recorder. As a group, create a short script that can be used by staff members conducting water pressure tests in local restaurants. Some ideas that you may want to include are:

• Potential public health threats resulting from contaminated water

• Explanation of the water pressure test

• Confirming the health department’s legal authority to order restaurant closure

• Consequences to restaurants refusing to close

Question 9: Are there language and/or literacy issues that should be considered when preparing to meet with restaurant owners in the area?

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Question 10: Communicating with the public during a disease outbreak or public health emergency can be called “risk communication.” What are some guidelines for risk communication?

Activity

People often have mistaken ideas about what is and is not acceptable to share with the public when engaging in risk communication. The table below lists several myths and realities related to risk communication. On your own, decide whether each statement is accurate, and write “myth” or “reality” next to the statement. Then discuss your answers as a group.

Risk Communication Myths and Realities

|Statement |Myth or Reality? |

|Telling the public about a risk is more likely to unduly alarm people than keeping quiet.| |

|You should pay as much attention to dealing with people as you do to explaining the data.| |

|You should not go to the public until you have solutions to health threats. | |

|If you listen to the public, you will devote scarce resources to issues that are not a | |

|great threat to public health. | |

|Everyone in the health department should understand the basic principles of risk | |

|communication. | |

|It is okay to provide technical information to the public. | |

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Group Brainstorm

Often, after an outbreak investigation or a public health emergency, an Epi Team reviews the investigation in a “hot wash” or after-action review. The questions below are examples of questions that could be used in such a review. Choose one member of the Epi Team to record responses on a flip chart. As a group, discuss one or more of the following questions.

• What aspects of the water pressure investigation were successful?

• All public health emergencies present unique challenges. What characteristics of this emergency made it challenging?

• What areas of the investigation could have been improved?

• How does your local health department reach out to the local business community?

• If a similar water crisis occurred in your county, do you think that your Epi Team would be prepared to handle it?

• In this emergency, the county board of commissioners was supportive of the health director’s decision to close restaurants without sufficient water pressure. Describe the relationship between the local health department and the county board of commissioners in your county.

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Update – 2 pm, September 9th

To identify which restaurants must close and which may remain open, you need to determine whether each restaurant has sufficient water pressure. Your environmental health specialist develops a simple test to evaluate restaurant water pressure based on flushing a toilet. If there is enough water pressure to completely flush away a single piece of toilet paper while the sink faucet is running, the staff should be able to wash their hands and use the toilets safely, and the restaurant can remain open. If the single piece of toilet paper cannot be flushed, the restaurant should be ordered to close.

Update – 9 am, September 9th

The health department receives reports of many restaurants continuing to operate despite insufficient water pressure to maintain sanitation standards. Without good water pressure, staff cannot wash their hands, use the bathroom, or properly sanitize cooking/eating utensils, all of which violates North Carolina’s sanitation codes.

The board of commissioners is concerned about the risk of a disease outbreak due to poor sanitation in many restaurants. The county depends on tourism for a substantial amount of its annual revenue, and a disease outbreak from an unsanitary restaurant could adversely affect the tourist season. After getting approval from the board of commissioners, the health director decides to investigate the water pressure in every open food service establishment. He plans to require restaurants without sufficient water pressure to close.

Update – 3 pm, September 8th

The media is reporting that more people are eating at area restaurants due to the lack of residential water and continuing power outages. It is not clear whether restaurants are following the Boil Water Advisory. In addition, there is another problem related to the water supply. The water authority director reports a lack of pressure in some parts of the system. The lack of pressure is not consistent across the water system. In fact, there are areas where buildings on one side of a street have potable water at proper pressure while buildings across the street have no pressure.

Update – 10 am, September 8th

The health director has activated the Incident Command System and asked your Epi Team to fill various roles within the ICS structure. Based on your recommendations, a Boil Water Advisory is issued to protect people from the contaminated water (see below). However, initial environmental health inspection reports from fast food franchise restaurants indicate that many have no ability to boil water due to specialized microwave technology in their kitchens. Some, but not all, restaurants have brought in bottled water to serve to customers.

Background

On September 7th, a severe tropical storm dumped 13 inches of rain in a single day in your region causing severe flooding. There have been power disruptions, broken water lines, and 1 death. The board of county commissioners has declared a state of emergency.

You work at the local health department (Springfield County) and are a member of the Epi Team. Of particular concern to you and your team is a report from the water authority director that the main reservoir line for the county water supply has broken and there has been contamination in the system.

Conclusion – September 11th

You contacted all local media using blast fax and held a press conference at noon to announce the restaurant inspection process. At your invitation, the first restaurant inspection was broadcast live by a local TV station. Fortunately, the owner cooperated and the restaurant passed the water pressure test. Teams of 2-4 staff members inspected all area restaurants that had not already closed. About 85% of these open restaurants did not pass the water pressure test. Most closed voluntarily, but 20 were ordered to close based on the local county ordinance prohibiting restaurants to operate without sufficient water pressure. The job was completed in 2 days, and so far there have been no reported disease outbreaks. The flooding has receded, and business in the county is resuming.

Update – noon, September 9th

After consulting with leaders in the county’s Incident Command System, the health director discovers that the local Emergency Operations Plan (EOP) has language that will allow the county to close local restaurants. The EOP states that the board of commissioners can issue an ordinance that prohibits the operations of business establishments in order to protect lives during a state of emergency. The board is willing to make such a proclamation. However, you know that some restaurant owners will question the county’s authority to close restaurants.

Update

The ICS Public Information Officer (PIO) asks several members of the Epi Team to work with her to create a press release for the general public.

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Tropical storm hits Springfield County

September

10 a.m.- Health director activates ICS, Boil Water Advisory issued

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Hurricane Phyllis hits Springfield County

September

3 p.m.- Water authority director reports lack of water pressure

3 p.m.- Water authority director reports lack of water pressure

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Hurricane Phyllis hits Springfield County

September

9 a.m.- Health director decides to investigate restaurant water pressure

9 a.m.- Health director decides to investigate restaurant water pressure

3 p.m.- Water authority director reports lack of water pressure

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Hurricane Phyllis hits Springfield County

September

September

2 p.m.- Environmental health specialist develops water pressure test

9 a.m.- Health director decides to investigate restaurant water pressure

3 p.m.- Water authority director reports lack of water pressure

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Tropical storm hits Springfield County

9 a.m.- Health director decides to investigate restaurant water pressure

2 p.m.- Environmental health specialist develops water pressure test

3 p.m.- Water authority director reports lack of water pressure

10 a.m.- Health director activates ICS, Boil Water Advisory issued

Tropical storm hits Springfield County

September

September

September

September

Local health department staff test restaurant water pressure. Most restaurants close voluntarily.

Hurricane Phyllis hits Springfield County

10 a.m.- Health Director activates ICS, Boil Water Advisory issued.

3 p.m.- Director of Water Authority reports lack of water pressure.

9 a.m.- Health Director decides to investigate restaurant water pressure.

2 p.m.- Environmental Health Specialist develops water pressure test

Local health department staff test restaurant water pressure. Most restaurants close voluntarily

2 p.m.- Environmental Health Specialist develops water pressure test

9 a.m.- Health Director decides to investigate restaurant water pressure

3 p.m.- Water Authority Director reports lack of water pressure

10 a.m.- Health Director activates ICS, Boil Water Advisory issued

Hurricane Phyllis hits Springfield County

Tropical storm hits Springfield County

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