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6/22/2017 » 6/25/2017
2017 OSAP Annual Conference

Boil Water Advisory Toolkit

Dental Guidance | Regulations | Global Resources | Videos



Safe drinking water is critical for home and business use including dental facilities around the world. In fact, safe water is one of the United Nations Millennium Development Goals. All public water systems in the US(supplying water to approximately 90% of the public) are required to follow the standards and regulations set by the Environmental Protection Agency (EPA). The EPA operates in partnership with the states, tribes, water systems and their operators.

Water systems regularly test for approximately 90 contaminants to make sure that no contaminant is present at levelsthat may pose a risk to human health. Unfortunately, water quality can sometimes change and despite the efforts of water suppliers, problems with drinking water can and do occur. When this happens, public water systems must notify their customers.

Dental Guidance

Boil-Water Advisories and the Dental OfficeFact Sheet from the US Centers for Disease Control and Prevention (CDC) lists actions to take when a boil-water advisory is in effect and when it is cancelled, alternative water sources and a variety of references and resources. BOTTOM LINE: DO NOT TREAT PATIENTS UNLESS THE DENTAL FACILITY HAS A WATER SOURCE THAT IS ISOLATED FROM THE MUNICIPAL WATER SYSTEM.
Dental offices during a boil-water advisoryCDC site focusing on Cryptosporidiosis ("Crypto") and lists general procedures, drinking wateroptions, hand hygiene and what to do whenthe advisory is cancelled.
Boil-Water information from CDC 2003 Dental Infection Control GuidelineA boil-water advisory is a public health announcement that the public should boil tap water before drinking it. When issued, the public should assume the water is unsafe to drink. Advisories can be issued after 1) failure of or substantial interruption in water treatment processes that result in increased turbidity levels or particle counts and mechanical or equipment failure; 2) positive test results for pathogens (e.g., Cryptosporidium, Giardia, or Shigella) in water; 3) violations of the total coliform rule or the turbidity standard of the surface water treatment rule; 4) circumstances that compromise the distribution system (e.g., water main break) coupled with an indication of a health hazard; or 5) a natural disaster (e.g., flood, hurricane, or earthquake) (346). In recent years, increased numbers of boil-water advisories have resulted from contamination of public drinking water systems with waterborne pathogens. Most notable was the outbreak of cryptosporidiosis in Milwaukee, Wisconsin, where the municipal water system was contaminated with the protozoan parasite Cryptosporidium parvum. An estimated 403,000 persons became ill (347,348).

During a boil-water advisory, water should not be delivered to patients through the dental unit, ultrasonic scaler, or other dental equipment that uses the public water system. This restriction does not apply if the water source is isolated from the municipal water system (e.g., a separate water reservoir or other water treatment device cleared for marketing by FDA). Patients should rinse with bottled or distilled water until the boil-water advisory has been cancelled. During these advisory periods, tap water should not be used to dilute germicides or for hand hygiene unless the water has been brought to a rolling boil for >1 minute and cooled before use (346, 349--351). For hand hygiene, antimicrobial products that do not require water (e.g., alcohol-based hand rubs) can be used until the boil-water notice is cancelled. If hands are visibly contaminated, bottled water and soap should be used for handwashing; if bottled water is not immediately available, an antiseptic towelette should be used (13,122).

When the advisory is cancelled, the local water utility should provide guidance for flushing of waterlines to reduce residual microbial contamination. All incoming waterlines from the public water system inside the dental office (e.g., faucets, waterlines, and dental equipment) should be flushed. No consensus exists regarding the optimal duration for flushing procedures after cancellation of the advisory; recommendations range from 1 to 5 minutes (244,346,351,352). The length of time needed can vary with the type and length of the plumbing system leading to the office. After the incoming public water system lines are flushed, dental unit waterlines should be disinfected according to the manufacturer's instructions (346).

Dental Do's and Don'tsOSAP has a terrific resource featuring Do's and Don'ts for Boil-Water Advisories, What-Ifs and more in its "CDC Guidelines: From Policy to Practice, a step-by-step implementation workbook"
Emergency disinfection of drinking water

US Federal Agencies and the Red Cross recommend these same four steps to disinfect drinking water in an emergency. Information, illustrations and even a online timer for 1 minute is included in this helpful EPA site.

Also available En español,En français,Arabic and Vietnamese.

Emergency planning & disaster recovery in the dental officeThe American Dental Association (ADA) presents this manual which includes information on boil-water advisories (see page 27). The ADA's information on this topic is directly from the CDC.
Dental guidance for MassachusettsThe Massachusetts Department of Public Health and Board of Registration in Dentistryissued boil-water guidance for dental professionals and auxiliary dental personnel providing oral health care in a variety of settings including dental offices, schools, clinics, nursing homes, hospitals and educational programs.

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Current Drinking Water RegulationsUnder the Safe Drinking Water Act (SDWA), EPA sets legal limits on the levels of certain contaminants in drinking water.
EPA's 3 categories (tiers) of public notificationDepending on what tier a violation or situation falls into, water systems have different amounts of time and waysto distribute the notice.Tier 1 is Immediate Notice and occurs where there is the potential for human health to be immediately impacted. Water suppliers must use media outlets such as television, radio and newspapers, and post their notice in public places.This is when a "boil water" alert occurs.
Types of violations and situations that would necessitate public notice

(1) Exceeding maximum contaminant levels (MCLs) or maximum residual disinfectant levels (MRDLs); (2) Violations of treatment techniques; (3) Monitoring and testing procedure violations; (4) Failure to comply with the schedule of a variance or exemption.

Other situations (not violations) which require notice include: (1) Occurrence of a waterborne disease outbreak or other waterborne emergency; (2) Ground Water Rule fecal indicator-positive source samples; (3) Exceeding the nitrate MCL in noncommunity systems that have been granted permission by the primacy agency to continue to exceed the nitrate MCL of 10 milligrams per liter (mg/L) (although they must not exceed 20 mg/l); (4) Exceeding the secondary maximum contaminant level (SMCL) for fluoride (community water systems only); (5) Operation under a variance or exemption; (6) Availability of unregulated contaminant monitoring results.

Multiple barriers to protect public healthDrinking water professionals have long known that the most effective way to protect consumers from the risk of contamination and waterborne disease is through a multiple barrier approach. The approach provides "defense in depth" against waterborne pathogens and chemical contaminants that can cause a variety of illnesses and conditions, some of them potentially fatal.Selecting and protecting sourcewater is the first consideration. Installing treatment methods to improve the quality of the source water comes next; followed by constructing, operating and maintaining well-engineered storage facilities and distribution systems. The final barrier is monitoring and public information to provide consumers with information on water quality and health.

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Global Resources

Global water, sanitation & hygieneThis site, organized by CDC, pulls together global "fast facts", health water sites, how to restore safe water and sanitation, and information on CDC's "Safe Water System" that helps empower communities to improve their water by using household treatment options.
Safer water, better health internationallyThe World Health Organization (WHO) published the first-ever reportdepicting country-by-county estimates of the burden of disease due to water, sanitation and hygiene highlighting how much disease could be prevented through increased access to safe water and better hygiene. This epidemiological evidenceand economic argument for fully integrating water, sanitation and hygiene in countries' disease reduction strategies. Click HEREfor progress on WHO's Millennium Development Goal related to safe water.
WHO Guidelines for drinking-water qualityWHO produces international norms on water quality and human health in the form of guidelines that are used as the basis for regulation and standard setting, in developing and developed countries worldwide.

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Video: Tap Into Prevention: Drinking Water Information for Healthcare ProvidersNote: OSAP could not locate this video but does provide access to the 30-page booklet that is supposed toaccompany the video.Supplemental materials for the video, "Tap Into Prevention: Drinking Water Information for Healthcare Providers"
Inspiring Video about the importance of clean water in HaitiTIME Magazine just issued its list for the 100 most influential people of 2010. Rahul Singh, a paramedic from Toronto, Canada made the list for providing three essentials to the people of Haiti after its devastating earthquake: medical aid, WATER and training.

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