This article describes a unique use of a city grant for waterborne disease stream sampling and health care practitioner survey in an urban watershed.
Urban-county government stormwater quality grants became available following an EPA suit. Advanced development in the city, without sufficient corresponding sanitary infrastructure, resulted in sanitary sewer overflows. Presence of human E. coli in neighborhood streams had been previously established by The Friends of Wolf Run (stream).
Our project encompassed an entire urban watershed; partnering health care practitioners, scientists, government officials and educators in an effort to protect and ultimately improve the health and safety of residents.
This project could be replicated in other areas with development, inadequate sewers, storms or flooding. The limitations we learned with the surveys, adjustments we applied and analysis of the results are candidly described in the article.
- IRB approval was obtained from: Lexington-Fayette County Health Department for release of their reported data. Also from Eastern Kentucky University and University of Kentucky to survey health care practitioners in their clinics in the watershed.
- Link to IRB Approval Contract
- There is no potential conflict of interest.
Terry Foody, RN, MSN
Certified Clinical Research Coordinator
Authors: Terry Foody, RN, MSN, John Poundstone, MD, MPH, Andrew Waters, RS,MPH, Julie Ribes, MD, PhD, Brian Murphy, MD, Ken Cooke,BS.
- Foody – independent certified clinical research coordinator,
- Poundstone –former Commissioner, Lexington-Fayette County Health Department,
- Waters – Regional Epidemiologist, Lexington-Fayette County Health Department,
- Ribes – Director of Clinical Microbiology, University of Kentucky,
- Murphy – Department of Infectious Diseases, University of Kentucky,
- Cooke – liaison, Friends of Wolf Run.
Wolf Run Watershed, Lexington, Kentucky
Introduction: In 2006, the city of Lexington, Kentucky was issued suit by the Environmental Protection Agency due to sewage contamination of surface water. The Urban County Government response was a plan to augment sanitary sewer infrastructures and pump stations, mitigate stormwater runoff/infiltration and award grants to neighborhood groups for improvement initiatives.
The Friends of Wolf Run Inc. secured approval for a neighborhood survey grant within their watershed. The ultimate objective of the grant was health improvement through sampling of urban stream water and survey of health care practitioners for evidence of waterborne disease.
Materials and Methods:
- Acquisition of 4 rounds of stream water at different sites.
- Testing at University of Kentucky Microbiology Laboratory for human waterborne disease pathogens.
- Survey of Health Care Practitioners (primarily disease code data registries) in
- Wolf Run Watershed zip codes for evidence of waterborne disease in their patient populations.
- An educational component on testing and survey process for professionals and community.
- Multidisciplinary partnerships in roundtable report discussions.
The findings from the water samplings and the survey of health sites returned no significant evidence of reportable waterborne disease.
Community involvement in response to environmental contamination, infrastructure inadequacies. Professional partnerships in testing, planning, surveys and education. Opportunity to enhance awareness and strategize for common solutions.
Applicable to other locations with water challenges due to urban growth or geographic locations.
COMMUNITY HEALTH IMPACT SURVEY
The city of Lexington, Kentucky was sued by the EPA and the state because the city’s sanitary and storm sewer systems were discharging millions of gallons of untreated and partially treated sewage and other pollutants into Fayette County creeks and streams each year.
In response, a Consent Decree was formulated that will mandate the City to operate a system that complies with the law and is not a threat to public health and safety.
The old (pump) station was unable to handle large flows of sewage during wet weather events, sending raw sewage into the creek.” 1
“The consent decree is a legal agreement between the city, state and federal government to fix problems with Lexington’s stormwater and sanitary sewer systems within 11-13 years.
Over the years, Lexington, Kentucky failed to properly maintain both the sanitary and storm water sewer systems. During significant rainfall, sanitary sewer overflows (SSOs) discharged sewage into city streams.
In 2006, the U.S. Environmental Protection Agency and the Commonwealth of Kentucky filed a lawsuit against Lexington for violations of the Clean Water Act. The consent decree agreement, which was finalized in January, 2011, required construction projects to repair sewer pipes, pumping stations and to improve the stormwater system. The agreement also required Lexington to make operational and managerial changes to prevent future problems.” 2
A resulting component of the aforementioned Consent Degree established Lexington Urban County Government Stormwater Quality grants for innovative projects to improve water quality, address stormwater runoff and educate the public on these issues.
The Friends of Wolf Run stream was awarded a Stormwater Quality Incentive Neighborhood Grant to conduct stream sampling to determine the existence of waterborne pathogens, and corollary health impacts on local residents through surveys of health care providers in the watershed.
Friends of Wolf Run Inc. had a long history of working with professional research scientists in the conduction of environmental studies and data in their watershed. The group had worked with federal, state, municipal, corporate and private foundation grants in the past. Through previous methodical sampling and testing, the existence of high levels of human pathogen indicators (E. coli) had been established in the Wolf Run stream.
A certified clinical research coordinator, Terry Foody, RN, MSN was hired as Project Coordinator for grant submission and implementation. An immediate, unforeseen challenge lay in explaining the project to the grant review board. Unlike medical institutional review boards, this one was smaller and consisted mainly of citizens on the municipal water board. Our proposal did not fit the other stormwater plans with requests for rain gardens, rainwater collection barrels, tree planting or even permeable pavement.
Our project was to address documentation of quality and safety in the neighborhood stream, specifically evidence of human waste and possibility of waterborne disease.
We proposed to accomplish this through microscopic analysis of systematically acquired stream samples and survey of the health care practitioners.
As part of our comprehensive plan to have partners on board from the start, we received a letter of interest and approval from the Director of the Department of Environmental Quality.
METHODS and MATERIALS:
The Community Health Impact Study had three components: sampling and analysis of water in Wolf Run stream for evidence of waterborne disease, survey of health care practitioners in the watershed for evidence of waterborne disease in their patient populations, and public education of the sewer situation and environmental stewardship.
From the onset, we incorporated various environmental stakeholders by requesting letters of support, interest and participation. This “urban water strategy” has been employed by other cities challenged with episodic overflows and flooding. “Get more and different stakeholders to the table and involved.”3
The intent of this study was to document the impact of pathogenic pollutants in surface waters as they pass through neighborhood backyards, playgrounds and commercial areas.
The presence of E.coli and fecal coliform bacteria had been established in the surface water of Wolf Run Stream. A plan was designed to test for more specific enteric human pathogens both viral and bacterial. The water sampling was obtained by trained Friends of Wolf Run volunteers using a standardized American Public Health Association and University of Kentucky Laboratory specified methods for collection, preservation and transport.
Four rounds of samples were to be drawn at various times and locations in the Wolf Run Watershed.
Julie Ribes, MD, a microbiologist at the accredited University of Kentucky Medical Center clinical laboratory, was secured in study partnership to do innovative, specific water sample testing for our study.
Three rounds of water sampling were obtained by the Friends of Wolf Run Creek and tested by Dr. Julie Ribes in the University of Kentucky’s Microbiology Laboratory. The fourth round, suspended due to prevailing drought conditions in late summer and fall, was eventually abandoned as samples were analyzed.
Dr. Ribes methods for Wolf Run water study reported 7-8-11:
Water samples were sent to the Clinical Microbiology Laboratory in a blinded method. Unconcentrated specimens (0.1-1ml samples) were inoculated onto solid medium and were streaked to isolation according to the laboratory’s stool culture procedure. The following media were utilized; Blood agar plate, Maconkey agar plate, Sorbitol Maconkey, XLD, CIN, Campylobacter medium, and CNA. Additionally, 1 ml aliquots of water were inoculated into Maconkey broth and selenite broth for overnight broth enrichment. Overnight Maconkey broth cultures were utilized for enzyme immunoassay testing for Shiga Toxin 1 and 2 (ImmunocardSTAT EHEC assay, Meridian Biosciences Inc, Cincinnati, OH), while the overnight selenite broth was used to inoculate solid XLD medium to enhance pathogen detection.
Un-concentrated specimens of water were placed in an equal volume of 10% formalin for Direct fluorescence antibody testing for Cryptosporidium and Giardia using Meridian Biosciences Inc. MerIFluor assay (Cincinnati ,OH). The specimens were centrifuged and pellets examined following the manufacturer’s instructions.
The Community Health Impact Survey was developed for this project with the input of research, environmental and medical experts.
The same day the grant was awarded, a preliminary planning meeting was held with Ken Cooke, Friends of Wolf Run grant administrator, Terry Foody, project coordinator and Dr. John Poundstone, former Health Department Medical Director, and medical advisor to the grant, to strategize completion of the grant objectives.
The next week, the project coordinator met with Andrew Waters, MPH, epidemiologist at Lexington Fayette County Health Department to establish a strategy for a survey of sites. The Wolf Run Watershed area map was examined by Mr. Waters to identify health care agencies. He had working knowledge of these agencies and provided names of possible contact persons.
At this time, Ms. Foody learned that in order to access the Health Department’s Disease Registry, a submission to their Institutional Review Board would be required.
A Community Health Impact Survey Tool was developed and written by Project Coordinator, Terry Foody, RN, MSN with input from the advisors, Dr. John Poundstone, MPH, and Dr. Brian Murphy, University of Kentucky Department of Infectious Disease (specialty in childhood diarrhea), regarding formation of survey tool and parameters to include for gathering of data.
The survey tool was reviewed and checked for validity and reliability by former
community health nurse Pat Wager, RN, BSN and certified clinical research coordinator Debbie Griffith, RN, MSN.
Institutional Review Board (IRB) submission was conducted with the Health Department for release of data from disease registries. Submissions were also made with, and permissions received from, Eastern Kentucky University IRB and University of Kentucky IRB for data from their clinics in the watershed.
Numerous health care sites in the Wolf Run Watershed were asked to participate in the survey. Fourteen sites, including offices, clinics and agencies were approached.
Practitioners from five sites supplied information on incidence of waterborne disease in their patient populations. Data was accrued from billing codes, using the key words diarrhea, or gastroenteritis.
Results included the laboratory water testing and responses to the community health surveys. Contributing geographic factors in the data included primary and secondary exposure to the stream (parks, playgrounds, housing).
As data was accrued and analyzed, it was noted that some sites also reported data from zip codes outside the requested area. It was suggested by our medical advisors to survey a few sites (zip codes) outside the watershed for comparison.
Although the survey asked for data from a two year time span, the sites responded with numbers from various time frames within the two years. This made the data practically impossible to analyze.
The water testing was stopped at three rounds, due to dry conditions.
We then applied for a second grant period, omitting the water sampling; continuing with the survey and education components. This time, the survey requested data from one year only for more uniformity.
In the second grant period, we expanded our survey, adding sites in areas of the city outside the Wolf Run Watershed. These areas were in the watersheds of other urban streams.
The Lexington Fayette Urban County Government’s Stormwater Quality grant required a strong educational component for the public.
The project coordinator developed a power point presentation based on local sanitary sewer history, basis for the EPA lawsuit, the city’s response, grant components, and preliminary findings.
The educational component was executed through partnership agencies and community
outreach. Partnership support was forthcoming from Tresine Logsdon, Director of Sustainability Education in Fayette County Public Schools. “I welcome your efforts to present relevant material from the surveys to teachers and classes. Part of our focus is the importance of environmental quality in the lives of our youth and their families.”
The project coordinator presented to university environmental interest groups, educator workshops, advanced science high school classes, neighborhood associations and nursing conferences.
At neighborhood festivals and community events, we set up a table to display study maps, blank survey samples and photos of colonized blood agar plates from Dr. Ribes’ laboratory. The Friends of Wolf Run produced a 48 x 36 full-color, stand-board map of the neighborhoods in the watershed delineating Best Management Practices for the environment. Our intent was to raise awareness of the study and the need for vigilant stream stewardship in the community.
Comments from the public who visited our table included: “We live in the area you studied!” “Where do the streams flow?” “Why was the city sued by the EPA?” “How will it get better?”
Environmental stewardship by all was emphasized in avoiding stormwater contamination and reducing runoff.
An innovative component of the project was two roundtable sessions, where stakeholders in the study came together for a progress report. These were strategically held in the conference room at the waste water treatment plant. Thus in addition to grant involvers; engineers, technicians and city commissioners attended as well to hear the process and see the results of our findings. At the first one, Dr. Ribes presented colorful slides of the early laboratory growth from the stream samples, igniting discussion on interpretation and implications.
Progress and results from surveys were also reviewed at both sessions.
Microbiology laboratory testing of the multi-site stream samples ultimately demonstrated no significant growth of waterborne human disease bacteria.
Dr. Ribes’ results of Wolf Run water study 7-8-11:
Three batches of water samples were submitted for evaluation. One hundred percent of the water samples contained one or more potential pathogens. (Table 1). Aeromonas spp. were the most frequent isolates found, with 1-2 isolates being seen in all but one (93%) of the samples analyzed. Pleisiomonas shigelloides was found in 2 specimens (13% of specimens) while Bacillus cereus was detected in 4 specimens (27%). Nine specimens (60%) had 2-3 organisms that could be human pathogens. None of the traditional Enterobacteraceae stool pathogens (enteropathogenic E. coli, Salmonella, Shigella, Yersinea, Edwardsiella) were detected in this water survey. Additionally, neither toxin 1 nor toxin 2 producing organisms were detected by EIA testing for these toxins. Neither Cryptosporidium nor Giardia were detected by DFA on the unconcentrated specimens.
A key component of this grant was a survey of health care practitioners for evidence of waterborne disease in their patient populations. Five sites from the previous grant participated with data from the three zip codes in the Wolf Run Watershed. Two of these five sites also provided data from patients in three zip codes outside the Wolf Run watershed.
In addition, we surveyed the health care practitioners and received data from seven new sites outside the watershed.
In total, the health care practitioners at the eleven participating survey sites sent data on 579 patients.
These results from the sites can be seen on tables #1-3.
Community Health Impact Survey of Waterborne Disease in Wolf Run Watershed, Lexington, Kentucky
Data is from original sites within the Wolf Run Watershed. All data was accrued during 2011. Zip codes are represented by letters (A,B,C)
|Agency/Zip code||Site – 1,B||Site – 2, A||Site 2, B||Site – 2, C||Site – 3, A||Site 3, B||Site – 4, A||Site – 4,B||Site – 4, C|
|No. of Cases||36||71||75||11||4||24||14||48||0|
|Females||36||w-22/ b-1||w-31/b-1||w-3/b-1||Total||283 cases||gastroenteritis|
Chart of reportable diseases within Wolf Run Watershed
from Lexington Fayette County Health Department.
Note: the above sites were surveyed for these diseases, but none were reported to the study
|Disease Condition||LFHD- A||LFHD-B||LFHD – C||Total – 12|
|Shiga Toxin-Producing E. Coli(STEC)||1||1|
Data from areas outside the Wolf Run Watershed
|Agency/Zip||Site – 5,X||Site -4,X||Site – 4, Y||Site – 4, Z||Total – 90|
|Confirmed Condition||LFCHD-X||LFCHD-Y||LFCHD-Z||Total – 19|
|E. coli (STEC)||Adult||1|
Data from five new sites, two with new areas. All are outside of Wolf Run Watershed
All patient visits were in 2011
|Site – 6, X||Site – 7, X||Site – 8,Z||Site – 8, W||Site – 9, V||Total|
Grand Total from sites outside Wolf Run Watershed 204 cases gastroenteritis
Analysis of the data
Although indicated on the survey, the practitioners did not ascertain contact with the stream by their patients. Data was collected from patient visits during previous years. Some of the sites outside the Wolf Run watershed were in localities of other urban streams; thus also affected by sanitary sewer overflows.
Comments from the grant’s medical advisor, Dr. John Poundstone, MD, MPH: “I’m afraid there wasn’t much to get excited about in this data. The Health Department data was the most interesting in that it lists actual diagnoses. Except for six cases of salmonella on one chart, I don’t see much to say. Watery diarrhea from several sites is probably par for the course without further investigation.”
Anecdotal comment from one site: “We are a student-run free clinic held two evenings/wk. We see few cases of diarrhea and are unequipped to test for specific pathogens. Most of our patients are homeless – would use Emergency Dept for treatment.”
Survey results of health care practitioners from sites within and outside the Wolf Run watershed demonstrated no reportable waterborne disease in their patient populations.
“Although there are more cases of gastroenteritis in Wolf Run, there’re more diagnosed ones outside the watershed. Since we don’t have a population to base rates on it would difficult to say there are significant differences. Also we don’t have enough specific information where the cases may have contacted the pathogen. Doing comparisons based on geography only (square miles in the watershed vs rest of the county) would not be that helpful in my estimation.” John Poundstone, MD, MPH
Lexington experienced a draught the summer the stream samples were collected. This may have impacted the laboratory results.
There was also a massive world equestrian event in the city that required the services of all health inspectors. As a result, the Health Department’s IRB docket pulled up in the stirrups and our data request was delayed.
There was disparity between the health department’s disease data and the survey reports. None of our sites had seen certain pathogens that had been reported to the health department. However, except for one site, we were unable to obtain participation from private medical practices, which may account for those cases.
Our survey results came from clinics that were conducted by practitioners from the University of Kentucky college of medicine, Eastern Kentucky University college of nursing, a private clinic with multiple offices, nurse practitioner (and medical school) clinics in elementary schools, treatment facilities, and homeless shelters.
Some of the sites that refused the survey had no way to access their data as they did not bill their patients or had no staff to obtain the information. At some sites, the practitioners themselves obtained the data for us.
Our project was built on layers of involvement: Friends of Wolf Run, watershed residents, professionals, schools, government and community agencies.
A desired outcome would be the improvement of storm water quality/residential health through evidence to city officials and the public, of existing levels of contamination.
Objectives embedded in the educational presentation included an understanding of the process of human contamination, importance of intact sewer system for disease-free storm water, and the role of the environment in health. A number of professionals in public health and epidemiology were informed of the grant process and results through the project coordinator’s talks. This increased the recognition and effectiveness of the watershed/neighborhood group in partnership with the community health stewards.
The purpose of our project was to have an impact on the health of residents in the greater Wolf Run Watershed. Our intent was to contribute to the improvement of the water quality and resident safety in the area by innovative water testing, community survey and subsequent education of the public on the resulting issues enlightened by our efforts.
We disseminated reports of our findings to a variety of groups such as:
Lexington- Fayette Urban County Government and Kentucky Environmental Policy and Water Quality Divisions, Urban County Council and the Mayor’s office, in addition to postings on the Friends of Wolf Run web site.
At the time of the survey, most of the health care practitioners were either unaware of the stream’s existence, their proximity to it, or their client’s interaction with it. These clinics need to be included when planning neighborhood stream education and interaction events.
At the presentations and community events, some people were already informed of the EPA suit and Lexington’s efforts to correct. Our information helped to clarify misconceptions and augment incomplete information. This project enhanced understanding of the interplay of sound sanitary infrastructure and pure, thriving urban streams.
Roundtables and Partnerships
Our Roundtable sessions enhanced the effectiveness of our partnerships through dissemination of findings. Discussion included indications within the scope of the grant, ramifications for the urban area at large and possibilities for future scientific inquiries within the watershed.
As a method of addressing environmental sustainability in growing communities, roundtables engage stakeholders to help shape future partnership efforts. Their value is enhanced by making collaborative, interagency approaches. Public health surveys of environmental conditions can be an integral part of this “new way of doing business.”4
Survey, Science, Education for Health
The three-pronged approach of our community health survey could be replicated by other communities through incorporating desired partners from neighborhoods, science, epidemiology, education and government. Once established, these liaisons could be implemented in a myriad of environmental challenging situations as conduits for collaborative public health solutions.
Appreciation to the health care practitioners for their work on the surveys, and to Robert Shapiro, Public Health Librarian, University of Kentucky Medical Center Library.
Public Health Reports Community Health Impact Survey
In Wolf Run Watershed, Lexington, Kentucky
- Martin T. Lexington EPA consent decree signed by judge. Business Lexington [Internet]. 2012
Mar 2: Available from: http://bizlex.com/2012/03/lexington-epa-consent-decree-signed-by- judge
- Consent Decree, United States of American and The Commonwealth of Kentucky v. Lexington-
Fayette Urban County Government (No 5:06-cv-00386-KSF, Doc #: 77, Jan 3, 2011), Available
- Rosenbloom S, Oo E, Cosgrove J, and Karakul C. Urban water: strategies that work [Internet].
Washington, D.C.: Urban Institute; 2013 Dec [cited 2016 Apr 16]. 76 p. Available
- Department of Housing and Urban Development, Department of Transportation, and Environmental Protection Agency. Partnership for sustainable communities: five years of learning from communities and coordinating federal investments [Internet]. Washington, D.C.: Office of Sustainable Communities; 2014 Aug [cited 2016 Apr 16]. 24 p. Available from: https://www.sustainablecommunities.gov/sites/sustainablecommunities.gov/files/docs/partner ship-accomplishments-report-2014-reduced-size.pdf