CDC Examines Impact of Water Loss on Communities

April 1, 2011
A recent study by the Centers for Disease Control and Prevention (CDC) examined the potential health impacts of an extended loss of water service to communities.

A recent study by the Centers for Disease Control and Prevention (CDC) examined the potential health impacts of an extended loss of water service to communities. The study focused on two rural communities in Alabama that lost municipal water service for nearly two weeks because of weather-related water main breaks and mechanical failures.

Investigators found that residents who had low water pressure or no water service for at least a week reported 2 to 3 times more vomiting or diarrhea than residents who did not experience water shortages. Less than half of the residents heard about boil water advisories at the beginning of the emergency, and 30 percent of residents drank unboiled tap water, indicating that emergency response messages were not reaching all members of the community.

The investigation revealed that households, communities, water utilities, and institutions were not adequately prepared for water emergencies in areas of communication and notification, planning for alternative water sources, and interagency coordination. Individual households also were not adequately prepared for the duration of the water emergency.

As a result of this investigation, CDC has developed a series of recommendations for public health involvement in water emergency preparedness.

The two communities, only identified as "Community A and B" are located in two predominantly rural counties in southwestern Alabama and have a combined population of about 18,000 residents. They are served primarily by three interconnected public water utilities.

Because freezing conditions are rare in this area, few building codes require burial or insulation of residential water pipes. From January 4-11, 2010, overnight low temperatures ranged from 12°F to 22°F, causing many utility water mains and residential water pipes to break. The resulting systemic water loss and related mechanical failures forced water utilities to cut off service to most households in the two communities.

Local Alabama Department of Public Health (ADPH) offices did not learn about the water shortages until January 10 in community A, when a resident complained about restaurants operating without water, and January 11 in community B, when an ADPH nurse found a school operating without water. ADPH issued boil water advisories for both communities. Three agencies were involved in supplying emergency water to the affected communities: the Alabama Emergency Management Agency provided five truckloads of bottled water to community A and one truckload to community B; the National Guard delivered nonpotable water to community A; and ADPH deployed water filtration/UV disinfection units to both communities.

Household Survey

From February 26 to March 9, 2010, CDC and ADPH conducted a household survey to assess the extent of the water emergency and its effect on public health. Some 470 affected and unaffected households were surveyed to estimate acute gastrointestinal and/or acute respiratory illnesses; how many households suffered water loss or reduced pressure; how many were aware of the boil water notice; how many had emergency water provisions; and how the two communities responded to the emergency.

Of the 470 surveyed households, 108 (23%) reported water pipe breaks as a result of the January freeze. A total of 210 (45%) households had water stored for emergencies, but less than 10 percent had stored more than five gallons.

While 90% of the households had heard about the boil water advisory, less than 50% heard about it at the beginning of the water emergency and 30% reported drinking unboiled tap water. In community B, residents in 40% of the households said they heard about the boil water advisory from family, friends, or neighbors, and not from official sources.

In both communities, the majority of residents said they would prefer to receive emergency information via telephone. Television was the second preferred source, followed by radio. Word of mouth was least preferred.

Researcher determined that, in general, community emergency preparedness planning had not included collaboration with water utilities, plans had not outlined a clear chain-of-command structure and boil water notification procedures, and emergency water distribution did not meet the needs of vulnerable populations, such as senior citizens, persons with disabilities, and those with limited financial or transportation resources.

CDC Recommendations

Public health agencies can help prevent or mitigate the health effects from future water emergencies by working to improve community and household preparedness, and by developing effective communication strategies to reach affected populations before and during such emergencies.

CDC recommendations include the following steps:

Develop a water emergency response protocol

  • Develop notification procedures between agencies, utilities, and associations (including up-to-date rosters).
  • Establish a prioritization of facilities during water shortages.
  • Identify all institutions (e.g., businesses, schools, and hospitals) that need to be notified in emergencies and maintain current contact information.
  • Assess protocols and interagency responses through periodic drills and exercises.

Develop a water distribution plan

  • Identify vulnerable populations and provide for their aid during water shortages.
  • Develop a tiered hierarchy of preferred emergency sources of potable water (e.g., bottled, approved bulk water supply, or portable treatment devices).
  • Specify proper procedures and equipment for treating, transporting, and distributing potable water.
  • Identify options for providing the community with nonpotable water during longer-term shortages (with a clear distinction in packaging from potable sources).

Develop a community communications toolkit

  • Provide draft language for water emergencies and advisories (e.g., how long to boil water or how to obtain alternative water sources) using basic language (e.g., fifth grade comprehension level).
  • Use modes of communication that are locally preferred and effective (e.g., most frequently viewed TV channels or radio stations, telephonic community notification system when possible, notification through schools, and signage).
  • Provide targeted emergency messages for key facilities such as medical facilities, schools, and businesses.

Provide guidance for household preparedness

  • Increase emphasis on the need for a minimum 3-day supply of potable water for emergencies.
  • Supply information on how to protect pipes and identify vulnerabilities to freezing, targeting rural areas that lack building codes and owners of vacation homes who might not be present to detect burst pipes.
  • Evaluate effectiveness of current emergency preparedness campaigns (e.g., complexity of messaging and application to year-round preparedness).

Provide guidance for institutional preparedness

  • Provide guidance and training to ensure that health-care facilities, schools, and businesses know how to maintain their operations to protect the public's health during a loss of water service.
  • Consider developing tools and templates or sample emergency plans that can be downloaded from the public health agency's website and adapted to individual facilities. Make these available to all institutions, regardless of whether a public health agency normally oversees their operations.

An article on the study, "Community Health Impact of Extended Loss of Water Service - Alabama, January 2010," was published in the February 18, 2011, CDC Morbidity and Mortality Weekly Report. To read the article on-line, visit and click on the "Weekly Report" menu for back issues.

The CDC maintains a "Preparedness Toolkit" website to help agencies before, during and after a water emergency. The Toolkit includes information and training courses on water-related emergency topics such as obtaining safe water, well remediation, septic system remediation, hygiene, and worker safety. Visit


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