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CHAPTER 1
Purpose of Physician On-Line Reference Guide
General
Introduction for Practicing Clinicians and Primary Care Practitioners:
Recognizing and treating waterborne disease and the health effects
of acute and chronic exposure to water pollution is a diagnostic dilemma
for the majority of practicing physicians in the United States. Health
care practitioners face many challenges when attempting to accurately
diagnose and appropriately manage and treat waterborne disease and
the sequelae of acute and chronic exposure to waterborne contaminants.
These significant challenges include but are not limited to the following
scenarios:
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Many of the signs and symptoms of waterborne disease and the health effects
of water pollution are non-specific and often mimic more common
medical conditions and disorders (1).
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Patients may not be aware of previous waterborne exposure and may not provide
an accurate exposure history. In addition, many of the pathogens
and chemical contaminants found in the water environment are not
unique to water and may exhibit multiple routes of exposure and
result from other sources of environmental contamination (2,3).
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Waterborne exposure events in a healthy patient population often present as
benign symptoms or self-limited illness while the same waterborne
exposure events in a vulnerable patient population may result in
significant morbidity including chronic and life-threatening disease
(4).
Largely due to the development of modern water treatment technologies, waterborne
disease is no longer a principal cause of major illness and death
in the United States as was the case in the 1800's.
However, the Centers for Disease Control and Prevention (CDC) estimate that approximately
900,000 cases of waterborne disease occur each year in the United
States possibly resulting in 900 deaths (5).
These estimates may not completely reflect the magnitude of
this problem
since inadequate diagnosis and underreporting of cases of waterborne
disease by medical practitioners may confound waterborne disease
surveillance
programs and chemical exposure registries. Misdiagnosis and delayed
recognition of cases by physicians may lead to inaccurate
assessment
of the prevalence and incidence of waterborne disease in the U.S.
and, in some instances, may lead to a serious public health
threat.
Consequences of Misdiagnosis of Waterborne Disease and Water Contamination:
The massive outbreak of waterborne cryptosporidiosis in Milwaukee,
Wisconsin in 1993 is an example of how contaminated water distributed
through a municipal water system can result in significant medical
and public health consequences in a community (3).
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An estimated 403,000 Milwaukee residents developed diarrhea reflecting
an attack rate of 52% of the population that was served by the affected
municipal water system (6).
-
More than 4,000 Milwaukee residents were hospitalized during the
waterborne
outbreak with cryptosporidiosis listed as the underlying or contributory
cause of death in 54 residents following the outbreak (7).
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It has been estimated that 725,000 productive days were lost at a cost
in excess of $54 million in lost time or additional expenses to
residents and local authorities in Milwaukee as a result of the
outbreak (8).
This
example illustrates the critical importance of practicing physicians
correctly identifying waterborne disease and the health effects of
water pollution -- if the health of their individual patients
as well
as the public health of their community are to be protected. Local
community physicians generally provide the first warning to health
authorities and water utility practitioners of the possibility of
a waterborne outbreak. These sentinel notifications will continue
to gain importance in the future in the face of increasing challenges
presented by emerging waterborne pathogens and potential terrorist
threats to water safety. Any future strategic plan to maintain and
improve water quality in the United States must include practicing
physicians as active participants in this public health effort.
Clinical
Constraints and Time Restrictions of Practicing Clinicians:
Unfortunately, the majority of practicing physicians in the United
States have received no formalized training in the recognition and
evaluation of waterborne disease or in the management of the short-
and long-term health effects of water pollution. Currently, there
is a paucity of direct educational outreach programs in the United
States that provide practicing primary care physicians with clinically
relevant information addressing the diagnosis, evaluation and management
of waterborne disease. Several additional barriers exacerbate this
critical information gap including:
-
Practicing
primary care physicians are confronted with a massive volume of
new medical information and research publications in their daily
clinical practice. Unfortunately given the time restraints of many
busy clinicians, incorporating any new clinical information into
their clinical practices (particularly information addressing waterborne
diseases) is a very difficult challenge (9).
-
A
report from the National Academy of Sciences Institute of Medicine
targeting the "Role of the Primary Care Physician in Occupational
and Environmental Medicine" emphasized that one of the leading
concerns of primary care physicians attempting to address environmental
exposure and disease is: 1) lack of informational support available
to primary care practitioners and 2) lack of a "single-access
point" for the type of pertinent information necessary to appropriately
evaluate the environmental exposure under clinical consideration
(10).
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Even
practicing physicians who are most likely to care for patients presenting
with symptoms of waterborne disease are frequently unaware of the
disease characteristics and do not consider or order the appropriate
diagnostic testing. In a recent survey, more than 75% of gastroenterologists,
general or family practitioners, internists and pediatricians never
or rarely tested for Cryptosporidium even though their patients
presented with symptoms that were consistent with the waterborne
disease (11).
Patient
Expectations and New Diagnostic Challenges:
As described above, practicing physicians may be unfamiliar with how
to recognize and manage waterborne diseases and the health effects
of water pollution. However, several recent studies indicate that
the general public trusts health care providers more than other informational
sources to provide them with accurate information regarding environmental
health risks including information addressing waterborne disease.
Two recent surveys concluded that health care providers play a central
role in providing information to their patients regarding water quality
and safety:
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Although
physicians may possess a very limited understanding of water-related
issues, healthcare providers are among the most trusted sources
of information for the general public regarding drinking water quality
and safety in the United States (12).
-
Information
regarding drinking water safety and risk reduction education was
more likely to result in preventive behaviors by patients if the
information was provided by a healthcare provider rather than another
source (13).
Physicians
must also embrace the fact that they may be faced with even more complex
and challenging diagnostic dilemmas when evaluating their patients
for possible exposure to waterborne disease or the health effects
of water pollution and contamination in the future. These new
challenges include but are not limited to:
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Emerging
infectious diseases continue to challenge our clinical knowledge
base with the incidence of disease increasing yearly. In addition,
many new infectious diseases have been identified over the past
10 years (14). Several of these new pathogens
may be transmitted through waterborne exposure.
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An
estimated 64,000 chemicals are in use commercially in the United
States with approximately 700 new chemical agents synthesized each
year. Of these many compounds, approximately 500 chemicals have
been
evaluated for carcinogenic potential with the mass majority never
being subjected to thorough toxicity testing for human health
effects
(15). Physicians may be faced with patients who
are concerned about the potential health effects of hazardous
chemical
agents that may have contaminated their drinking water source from
industrial use or production of these many compounds.
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Although
efforts to protect the security of the nation's 168,000 public drinking
water systems remain resolute (16), physicians
must work in collaboration with those responsible for protecting
the safety of drinking water reserves from terrorist attacks. The
Center for Disease Control and Prevention (CDC) recently called
upon primary care practitioners to remain vigilant, as they will
probably be the first to observe and report unusual disease trends
allowing for early detection and subsequent control of biological
and chemical assaults on the nation's infrastructure (17).
Objectives and Principles of this Physician On-Line Reference Guide:
In light of the significant challenges described above, providing
access to scientifically credible and clinically relevant information
is critical in order for healthcare providers to accurately diagnose
and manage waterborne disease and the health effects of water pollution
in their clinical practice. The changing nature of water pollution
issues and the continuing emergence of waterborne infectious pathogens
require specific attention to current and consistently up-to-date
information. In addition, any effective educational resource must
address the issues that all treating practitioners face in their daily
clinical experience. Barriers to accessing this type of specialized
environmental health information include: 1) significant time constraints
in the clinical setting and 2) competing priorities from other health
care issues. In order to provide useful information to the medical
community with respect to the recognition of waterborne disease and
the health effects of water pollution, innovative presentation strategies
are essential that incorporate all of these factors.
Organizing
the "power of the Internet" offers one of the best opportunities
for providing practicing physicians with relevant, reliable and current
information addressing the complex nature of waterborne disease and
the health effects of water pollution. Therefore, we have organized
this physician reference guide based upon the wealth of information
available through use of computer technology and Internet-based informational
resources. For
more information detailing the Focus and Key Points of this Physician
On-line Reference Guide, click here.
Free
Access to Physician On-line Reference Guide:
We trust that you will find this Physician On-line Reference Guide
a valuable informational resource as you approach the many aspects
of addressing the recognition and management of waterborne disease
and the health effects of water pollution. Access to this On-line
Physician Reference Guide is provided to health care practitioners
at no cost. This resource has been funded by the Environmental Protection
Agency, American Water Works Association and the Arnot Ogden Medical
Center. In
order to obtain free access to the remainder of this Website please
click here to sign in.
Continuing
Medical Education (CME) Offering for Physician On-Line Reference Guide:
The
American College of Preventive Medicine (ACPM) and Dr.
Patricia L. Meinhardt, a representative of ACPM, have developed
a Continuing Medical Education (CME) module of this Physician On-Line
Reference Guide. This Continuing Medical Education (CME) online resource
is intended to provide healthcare professionals with an educational
experience that will 1) improve their diagnostic acumen in the recognition,
treatment and prevention of waterborne disease and the health effects
of acute and chronic exposure to water pollution; 2) increase their
working knowledge of waterborne disease surveillance and exposure
pathways and 3) enhance their risk communication skills and strategies
when providing information to their patients regarding water quality
and safety in their clinical practice.
The
American College of Preventive Medicine (ACPM) is accredited by the
Accreditation Council for Continuing Medical Education (ACCME) to
provide CME credits for physicians participating in this continuing
medical educational activity. Through ACPM, Category 1 credits toward
the American Medical Association (AMA) Physician's Recognition Award
(PRA) are offered. ACPM will award a Continuing Medical Education
(CME) Certificate to physicians (MDs, DOs) completing this educational
activity and a Certificate of Participation to non-physicians
participating in this continuing education.
This
CME online course is organized into 10 chapters that represent
the
chapters of the Physician Online Reference Guide included
in this CME online offering. These chapters represent a comprehensive
core curriculum of clinically relevant information and specialized
educational resources for practicing physicians in several major
areas
of increasing importance and growing concern among those responsible
for protecting public health and water safety. The ACPM designates
this educational activity for a maximum of 22 hours in Category
1 credits toward the AMA Physician's Recognition Award. Each physician
should claim only those hours of credit that he or she actually spent
in this educational activity. CME credit can be earned for the entire
course OR for individual chapters of Recognizing Waterborne Disease
and the Health Effects of Water Pollution: A Physician Online Reference
Guide.
To
review information regarding this CME offering, please click here
to sign in.
References:
Selected references are available in full text by clicking on the
highlighted text below.
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Drinking
water and disease: what every healthcare provider should know. Physicians
for Social Responsibility. Washington, DC, 2000.
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Brooks
SM, Benson L, Gochfeld M. Types and sources of environmental hazards.
In: Brooks SM, Gochfeld M, Jackson R, Herztein J, Shenker M, eds.
Environmental Medicine. St. Louis, Missouri: Mosby, 1995:9-29.
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Ford
TE, MacKenzie WR. How safe is our drinking water? Postgraduate Medicine
2000;108:11-14.
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Meinhardt,
PL, Casemore DP, Miller, KB. Epidemiologic aspects of human cryptosporidiosis
and the role of waterborne transmission. Epidemiologic Reviews 1996;18:118-136.
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Microbial
pollutants in our nation's water. American Society for Microbiology.
Washington, DC, 1999.
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Mackenzie
WR, Hoxie NJ, Proctor ME, et al. A massive outbreak in Milwaukee
of Cryptosporidium infection transmitted through the public water
supply. New England Journal of Medicine 1994;331:161-7.
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Hoxie
NJ, Davis JP, Vergeront JM, et al. Cryptosporidiosis-associated
mortality following a massive outbreak in Milwaukee, Wisconsin.
American Journal of Public Health 1997;12:2032-5.
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Cryptosporidium
in water supplies: second report of the group of experts. Chairman,
Sir John Badenoch. London, England: HMSO, 1995.
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Richardson
WS, Mulrow, CD. Lifelong learning and evidence-based medicine
for
primary care. In: Noble J, Greene HL, Levinson W, et. al, eds.
Textbook of Primary Care Medicine, 3rd ed. St. Louis, Missouri.
Mosby, 2001:2-9.
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Sublet
VH. Good information about hazardous substances. In: Brooks SM,
Gochfeld M, Jackson R, Herztein J, Shenker M, eds. Environmental
Medicine. St. Louis, Missouri: Mosby, 1995:755-762.
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Morin
CA, Roberts CL, Mshar PA. What do physicians know about cryptosporidiosis?
Archives of Internal Medicine 1997;157:1017-1022.
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The
national report card on safe drinking water knowledge, attitudes
and behaviors. National Environmental Education and Training Foundation
and Roper Starch Worldwide. Washington, DC, 1999.
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Griffin
and Dunwoody. The relation of communication to risk judgment and
preventive behavior related to lead in tap water. Health Communication
2000;12:81-107.
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Strausbaugh
LJ. Emerging infectious diseases: a challenge to all. American Family
Physician 1997;55:111-117.
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Philp
RB. Environmental hazards and human health. Boca Raton, Florida:
CRC Press, Inc. 1995:1-3.
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