World Water Day: How to Prepare for Water, Sanitation, and Hygiene Emergencies

Mar 22, 2019 | Michelle Shapiro

The theme for this year’s World Water Day, recognized annually on March 22, is “Leaving no one behind.” Billions of people around the world already live without access to safe water, and in emergencies, those numbers increase exponentially.

Across the United States, aging water infrastructure, severe weather, and accidents cause an estimated 240,000 water main breaks a year. These emergencies result in loss of service and boil water advisories, affecting public health and causing community-wide disruptions. With climate change-related surges in severe weather, as well as aging infrastructure, the frequency and severity of water, sanitation, and hygiene- (WASH-) related emergencies are expected to increase.

Local health departments (LHDs) are often called to respond to WASH emergencies in their communities, so they need the appropriate tools to prepare and respond in a timely manner. Recent WASH emergencies have demonstrated the importance of preparedness, and these examples can be used as learning opportunities to prepare water utility companies, public health departments, and emergency managers for future water emergencies.

Recognizing the importance of connecting LHDs across the country to share their experiences preparing for and responding to WASH emergencies, NACCHO formed the WASH Emergency Preparedness and Response Workgroup, comprised of LHDs, academic institutions and federal agencies. The workgroup identifies common challenges in responding to WASH emergencies, shares resources and tools used in WASH emergency response, and evaluates how existing tools can be improved to better equip health departments.

In collaboration with the workgroup, NACCHO released a compendium of case stories demonstrating LHD efforts to prepare for and respond to complex water emergencies in their communities. Below are excerpts of each story.

Read the full WASH Emergency Preparedness Stories from the Field compendium.

City of Milwaukee Health Department, Wisconsin

During the summer and fall of 2013, the City of Milwaukee Health Department (MHD) responded to a Legionella outbreak that caused 58 clinically diagnosed cases. Typically, about six to eight cases are reported every year. The health department led the investigation, identifying improperly maintained cooling tower units as the likely source of the outbreak. Local public health staff worked closely with the Wisconsin Department of Health Services (WDHS), as well as local building owner maintenance associations; heating, ventilation, and air conditioning (HVAC) contractor; and neighborhood services during the response. HVAC contractors, responsible for maintaining commercial building cooling tower units, helped the MHD identify poorly maintained units within the city.

The outbreak primarily affected middle-aged and older adults with underlying chronic health problems and/or a history of smoking. One hospitalization was documented, and there were no deaths. Most confirmed and suspected cases were located in Milwaukee within a defined radius of buildings with cooling towers that were sampled by the MHD and found to have Legionella bacteria contamination.

The MHD encountered many challenges while responding to the outbreak. It was difficult to pinpoint any common source of exposure or location between reported cases. Many of the cases were reported by people suffering from underlying health conditions, making them potentially susceptible to opportunistic bacteria and viruses that are ubiquitous in the environment. The environmental assessment and sampling expertise and capacity were not readily available to mobilize in testing of indoor and outdoor building environments. In addition, engaging the media effectively quickly became time consuming in terms of building public awareness and launching effective risk communication to avoid public panic.

Learn how MHD overcame these challenges.

Washington County Public Health, Oregon

The Pacific Northwest is sited in the Cascadia subduction zone (CSZ). A CSZ earthquake can produce a magnitude 9.0, minutes-long earthquake that would result in significant destruction along the almost 700 miles of impact. This type of earthquake has an estimated 20% chance of occurring in the next 50 years. The Oregon Resilience Plan (Oregon Seismic Safety Policy Advisory Committee, 2013) anticipates that one of the results of this subduction zone earthquake will be catastrophic impacts to wastewater systems, with anticipated loss of wastewater systems for six months to a year. The areas affected include the Portland metro area, which has approximately 2.4 million residents. This loss will pose a significant public health threat in the aftermath of the earthquake, as adequate sanitation is a cornerstone of protecting the public’s health.

No clear guidance is available on how a large modern metropolitan area such as Portland would handle long-term disaster sanitation needs following a significant earthquake. The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response is focused on humanitarian responses to sanitation needs in developing countries. The websites of the Federal Emergency Management Agency (FEMA) and the Centers for Disease Control and Prevention (CDC) only address temporary sanitation needs, with a focus on flooding, and recommendations for use in developing nations.

A regional disaster sanitation task force of multi-disciplinary professionals from the five counties in the area was convened to develop recommendations to assist the public to safely handle their sanitation needs in the absence of a functional wastewater system for an extended period. Participants represented the disciplines of public health (including environmental health), emergency management, public works, wastewater treatment professionals, waste haulers, and the Oregon Department of Environmental Quality.

The mission of the group was to develop recommendations for the handling of human waste by residents of the Portland metropolitan region following a catastrophic earthquake.

Find out what recommendations the task force developed.

Public Health – Seattle and King County, Washington

Mercer Island is a city (population 25,000) in King County, Washington, which occupies a six square mile island of the same name, with its own municipal water utility, Mercer Island Utility Services (MIUS). That utility contracts routine surveillance testing to a much larger neighboring entity, Seattle Public Utilities. In October 2014, high levels of coliform bacteria were detected in the water supply. This prompted two back-to-back boil-water notices and on-site response from Public Health — Seattle & King County (PHSKC) Environmental Health Division. The PHSKC role included monitoring of food services establishments, public education, and facilitation of testing. Environmental health field personnel visited the nearly 90 food service establishments, including grocery stores, schools, nursing facilities, and restaurants, to ensure precautions were taken and food service operations were suspended as required by code. In addition, PHSKC provided guidance to residents on precautionary measures for the duration of the boil-water incident and surveillance for potential resultant illnesses.

Partnerships were vital to the successful intervention during this incident. Key partners and their roles included the Washington State Department of Health, the City of Mercer Island Office of Emergency Management, Seattle Public Utilities, MIUS, and the media.

Read about PHSKC’s key lessons learned from this incident.

For more information about NACCHO’s WASH preparedness work, contact Deise Galan Leonel at or Tiara Smith at


About Michelle Shapiro

Michelle Shapiro is a communication specialist for the Environmental Health & Disability team at NACCHO.

More posts by Michelle Shapiro

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