Do Not Drink, Do Not Boil: The 2014 Toledo Microcystin Advisory and the Public Health Nurse's Role in a Drinking Water Emergency
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Master of Science in Nursing Program, Aspen University
N680: Public Health Nursing
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Do Not Drink, Do Not Boil: The 2014 Toledo Microcystin Advisory and the Public Health Nurse's Role in a Drinking Water Emergency
Most people assume tap water is safe, and most drinking water emergencies are handled with a familiar instruction: boil before use. The emergency in Toledo, Ohio, in August 2014 was different. A bloom of cyanobacteria in western Lake Erie released microcystin, a liver toxin, near the city's water intake, and toxin was detected in treated water. The city told residents not to drink the water and not to boil it, because boiling kills bacteria but does not destroy the toxin and can concentrate it. Residents of the Toledo area went without safe tap water for more than two days (Steffen et al., 2017). This paper describes the hazard, identifies the populations harmed most, and sets out the public health nurse's role before, during and after such an event.
The Hazard
Cyanobacteria, often called blue-green algae, form dense blooms in warm, nutrient-rich water. In western Lake Erie, blooms dominated by Microcystis have occurred every summer since the mid-1990s, fed by phosphorus and nitrogen from agricultural runoff in the Maumee River watershed. Analysis of the 2014 bloom found that its cells were stressed for both nitrogen and phosphorus, suggested that urea from fertilizer may have been an important nitrogen source, and indicated that wind moved toxin-rich water toward the Toledo intake (Steffen et al., 2017). The causes of the emergency were therefore upstream and seasonal, and they will recur.
Microcystins primarily damage the liver. Short-term exposure through drinking water can cause gastrointestinal illness, and higher exposures can cause liver injury. The most severe known human event occurred in 1996 in Caruaru, Brazil, where water contaminated with cyanotoxins was used for hemodialysis: of 131 patients, 100 developed acute liver failure and 76 died, and investigators concluded that intravenous exposure to microcystins was the major contributing factor (Carmichael et al., 2001). For drinking water, federal health advisories issued in 2015 set ten-day values of 0.3 micrograms per liter for bottle-fed infants and children younger than school age and 1.6 micrograms per liter for school-age children and adults (U.S. Environmental Protection Agency [EPA], 2015).
Who Is Harmed Most
Environmental hazards are not shared equally, and a public health nurse's first task is to identify who is most vulnerable. Four groups stand out in a microcystin event. Infants who are fed formula mixed with tap water drink far more water for their body weight than adults, which is why the advisory value for young children is lower. People receiving dialysis, whether in a center or at home, face the gravest risk, as Caruaru showed, although dialysis water is normally treated further. People with liver disease, including those with hepatitis or heavy alcohol use, have less reserve to tolerate liver injury. And households without the money, transportation or physical ability to buy and carry bottled water, including older adults living alone, people with disabilities and families without cars, face the practical risk that they will drink the water because they have no alternative.
In Toledo, stores ran out of bottled water within hours, and residents drove to neighboring towns to find it. The people least able to do that were the same people whose health was most at risk.
The Public Health Nurse's Role Before an Event
Preparation happens in ordinary summers. Public health nurses can maintain a list of dialysis centers, home dialysis patients where registries exist, and facilities caring for infants, such as child care centers, together with contacts for each. They can work with the water utility and emergency management to agree in advance on how a do-not-drink advisory will be communicated, in which languages and through which channels, and on where water will be distributed. They can include cyanotoxin risk in teaching for families with infants, particularly those who use private wells or live near lakes, and advocate for agricultural nutrient reduction as a public health issue, not only an environmental one.
During the Event
When an advisory is issued, the nurse's roles are communication, protection of vulnerable groups and surveillance. Clear messages are essential because the instruction not to boil contradicts what people have been taught; messages should explain why in one sentence and state plainly what water is safe for drinking, cooking, mixing formula and brushing teeth. Nurses can contact dialysis centers and child care providers directly, arrange delivery of bottled water to homebound residents through partners such as meals programs and faith groups, and staff distribution sites. Surveillance means tracking calls to the poison center, emergency visits for gastrointestinal illness and reports from clinicians, so that any cluster of illness is detected quickly. Pets are also at risk, and many residents ask about them.
Rumors spread quickly in a water emergency, and nurses answering phones or staffing distribution sites hear them first. In Toledo, residents asked whether showering was safe, whether home filters removed the toxin and whether the water could be used to water gardens. Nurses can collect these questions each day and send them to the joint information center so that the next public message answers them directly, turning the nurse's contact with residents into better communication for the whole population.
After the Event
After the advisory is lifted, nurses help residents flush household plumbing according to utility instructions, answer questions about symptoms, and follow up any cases of illness. The department should review what worked, especially whether vulnerable residents received water, and revise its plan. Longer term, public health nurses can contribute to policy discussions about monitoring toxins at water intakes, upgrades to treatment, and reducing nutrient runoff, bringing data on who was affected to those decisions.
Conclusion
The Toledo advisory showed that environmental hazards can reach people through systems they trust, and that the protective action, not drinking, is hardest for the people with the fewest resources. Microcystin causes the most harm to infants, dialysis patients and people with liver disease, and the practical burden falls on households that cannot buy or carry water. Public health nurses protect these groups by preparing lists and relationships before the season, communicating clearly and delivering help during the event, and bringing the experience into prevention and policy afterward. As blooms recur each summer, that work is part of routine public health nursing, not an exception.
References
Carmichael, W. W., Azevedo, S. M. F. O., An, J. S., Molica, R. J. R., Jochimsen, E. M., Lau, S., Rinehart, K. L., Shaw, G. R., & Eaglesham, G. K. (2001). Human fatalities from cyanobacteria: Chemical and biological evidence for cyanotoxins. Environmental Health Perspectives, 109(7), 663-668. https://doi.org/10.1289/ehp.01109663
Steffen, M. M., Davis, T. W., McKay, R. M. L., Bullerjahn, G. S., Krausfeldt, L. E., Stough, J. M. A., Neitzey, M. L., Gilbert, N. E., Boyer, G. L., Johengen, T. H., Gossiaux, D. C., Burtner, A. M., Palladino, D., Rowe, M. D., Dick, G. J., Meyer, K. A., Levy, S., Boone, B. E., Stumpf, R. P., . . . Wilhelm, S. W. (2017). Ecophysiological examination of the Lake Erie Microcystis bloom in 2014: Linkages between biology and the water supply shutdown of Toledo, OH. Environmental Science & Technology, 51(12), 6745-6755. https://doi.org/10.1021/acs.est.7b00856
U.S. Environmental Protection Agency. (2015). Drinking water health advisory for the cyanobacterial microcystin toxins (EPA-820R15100). https://www.epa.gov/sites/default/files/2017-06/documents/microcystins-report-2015.pdf
How this N 680 Module 4 example is structured
Aspen does not publish N680 module prompts, so check your classroom for the exact instructions. This example explains one real hazard and its upstream causes, identifies vulnerable groups by biology and by social capacity, sets out the nurse's role before, during and after the event, and concludes on routine preparedness.
N680 Module 4 questions, answered
What does N680 Module 4 usually ask for?
Aspen's N680 description says the public health nurse must know the impact of the environment and disasters on health, so a paper analyzing an environmental hazard and the nurse's role is a typical assignment. Check your classroom for the prompt.
Why can't you boil water contaminated with microcystin?
Boiling kills bacteria but does not destroy microcystin, and evaporation can increase the toxin's concentration, so advisories tell residents not to drink or boil the water.
How should an environmental health paper address vulnerable populations?
Consider both biological susceptibility, such as infants or people with liver or kidney disease, and social capacity to avoid exposure, such as income, transportation, disability and language.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.