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Preservation of water quality and prevention of waterborne disease is a complicated task requiring a coordinated effort from many diverse disciplines including physicians, healthcare providers, epidemiologists, microbiologists, academic scientists, science researchers, local and national health authorities, public and environmental health specialists, water engineers and water purveyors. Any successful strategy to ensure water quality and safety in the United States must include the medical community as a valued stakeholder and active participant in this ongoing public health challenge. Unfortunately, the majority of practicing healthcare providers in the US has received limited training in the recognition and evaluation of water-related disease and faces many significant challenges and numerous barriers to diagnosing waterborne disease and the health effects of water pollution in their patients. The purpose of this review is to define the specific challenges facing the medical community with regard to clinical recognition of water-related disease and to provide recommendations for the development of specialized clinical resources and targeted educational outreach programs to assist the medical community in improving their ability to appropriately address water-related disease in their patients.

▪ Abstract Water supplies and water distribution systems represent potential targets for terrorist activity in the United States because of the critical need for water in every sector of our industrialized society. Even short-term disruption of water service can significantly impact a community, and intentional contamination of a municipal water system as part of a terrorist attack could lead to serious medical, public health, and economic consequences. Most practicing physicians and public health professionals in the United States have received limited training in the recognition and evaluation of waterborne disease from either natural or intentional contamination of water. Therefore, they are poorly prepared to detect water-related disease resulting from intentional contamination and may not be adequately trained to respond appropriately to a terrorist assault on water. The purpose of this review is to address this critical information gap and present relevant epidemiologic and clinical information for public health and medical practitioners who may be faced with addressing the recognition, management, and prevention of water terrorism in their communities.

As a result of the massive outbreak of waterborne cryptosporidiosis that occurred recently in Milwaukee, Wisconsin, affecting an estimated 403,000 individuals (1), there is renewed interest in the epidemiology, surveillance, and prevention of the emerging infectious disease caused by the protozoan parasite Cryptosporidiwn (2). Cryptosporidiwn is now recognized worldwide as a common cause of infectious gastroenteritis which characteristically results in a watery diarrhea that may sometimes be profuse and prolonged. The severity, persistence, and ultimate outcome of the infection is typically dependent on a variety of parasite characteristics and host factors. Although little is known regarding the pathogenic characteristics of the parasite, important host factors include both the immune status and frequency of exposure of the infected individual (3). In healthy, immunocompetent subjects, the disease most commonly presents as an acute, selflimited but often persistent enterocolitis. However, in immunocompromised and immunosuppressed individuals, particularly those infected with the human immunodeficiency virus, Cryptosporidium infection may be insidious in onset and may progress to a chronic and life-threatening disease resulting in multisystem involvement and mortality (3, 4). Although early reports of human cryptosporidiosis were often described in immunologically deficient adults, subsequent studies have confirmed that in many regions of the world peak incidence is seen among otherwise healthy children aged 1-5 years. Unfortunately, although more than 80 antimicrobial and chemotherapeutic agents