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A concerned PUC employee began to suspect something was wrong with Walkerton’s water. He had learnt
that the samples from the Highway 9 project had failed testing and phoned the MOE (Ontario) anonymously to
report his concerns and provide a contact number at PUC for the MOE to call about the Walkerton water
system. In the early afternoon of Saturday, 20 May, a MOE employee who received the anonymous call
phoned the GM to find out if there were problems with the system. The MOE employee was reassured that
any problems with bacteriological results had been limited to the Highway 9 mains replacement project some
weeks earlier. Later that evening, the concerned PUC employee followed up his call with the MOE, and
eventually the MOE agreed to contact the local MOE office (in Owen Sound) to look into the matter further.
The outbreak continued to expand. By Sunday, 21 May, there were more than 140 calls to the Walkerton
hospital, and two more patients were admitted to the Owen Sound hospital. A local radio station interviewed
the local Medical Officer of Health on Sunday morning and subsequently reported on the noon news that
drinking-water contamination was an unlikely source of this outbreak, but with little else to go on, a boil water
advisory was issued at 1:30 pm. This notice was provided only to the local AM and FM radio stations;
additional publicity by the television station or by direct door-to-door notification was not pursued.
The Health Unit established a strategic outbreak team to deal with the emergency. Local public institutions
were to be notified about the boil water advisory. By that evening (21 May), the Health Unit had notified
provincial health officials of the outbreak and requested the assistance of major hospitals in London and
Toronto in treating Walkerton residents and the assistance of Health Canada in conducting an epidemiological
investigation.
By Monday, 22 May, the Health Unit had received reports of 90–100 cases of E. coli infection, and the first
victim died. The regional MOE official in Owen Sound had been notified the previous evening about the
outbreak but did not initiate a MOE investigation, even after being advised about the large number of cases of
E. coli infection and that the Health Unit suspected the Walkerton water system. Only after being contacted
later that day by the local Medical Officer, who stressed the urgency of the situation, did the regional MOE
initiate an investigation by sending an environmental officer to Walkerton to meet first with the Health Unit
and then with PUC’s GM. The environmental officer was asked to obtain any microbiological test results from
PUC for the previous two weeks. The GM did not tell the officer about the adverse bacteriological results for
15 May, but did provide him with a number of documents, including the 17 May laboratory report. When the
officer reviewed the report, he did not report the alarming evidence of water contamination to his supervisor,
because he believed that the boil water advisory had eliminated any urgency.
In the meantime, the Health Unit was continuing its research, suggesting that the most likely date of
contamination was between 12 and 14 May and revealing that cases were distributed across the area served
by the Walkerton water distribution system. By that evening, the Health Unit was convinced this was a
waterborne outbreak, even though it had not yet been provided with the adverse results for 15 May.
On Tuesday, 23 May, the second victim died. The Health Unit also received bacteriological results from water
samples it had taken around Walkerton which had evidence of coliforms. When the Health Unit presented
these to the GM, he finally admitted to the adverse water quality results from 15 May (reported on 17 May).
Ultimately, 5 more deaths, 27 cases (median age of 4) of haemolytic-uraemic syndrome, a life-threatening
kidney condition that may subsequently require kidney transplantation, and 2300 cases of gastrointestinal
illness were attributed to the consumption of Walkerton water. The Ontario Clean Water Agency took over
operation of Walkerton’s water system. The boil water advisory was lifted on 5 December.
Note: As illness emerged in the community, the GM and Foreman of PUC remained convinced that water was
not to blame, and they continued to drink the water. In the past, they had often consumed Well 5 water
before chlorination, because they did not recognize the danger of pathogen contamination.
This case-study and exercise were adapted from Hrudey SE (2006) Fatal disease outbreak from contaminated drinking water in Walkerton,
Canada. Association of Environmental Engineering & Science Professors (AEESP Case Studies Compilation 2006;
http://www.aeespfoundation.org/publications/pdf/AEESP_CS_1.pdf).