1 2 3 4 THE NORTH BATTLEFORD WATER INQUIRY 5 6 7 8 9 10 11 12 * * * * * 13 14 BEFORE: The Honourable Justice Robert D. Laing 15 16 17 HELD AT: Tropical Inn, 18 North Battleford, Saskatchewan 19 20 * * * * * 21 22 23 24 October 10, 2001 25

1 APPEARANCES: 2 JAMES RUSSELL, Esq. ) 3 CHRISTOPHER BOYCHUK, Esq. ) Commission Counsel 4 BLAIR BLEAKNEY, Esq. ) 5 6 WARREN E. BICKFORD ) Executive Director 7 NORM DOELL ) Registrar 8 9 L. TED PRIEL, Q.C., Esq. ) The City of North 10 KEN A. STEVENSON, Q.C., Esq. ) Battleford 11 GARY D. YOUNG, Q.C., Esq. ) The Battlefords 12 MARK VANSTONE, Esq. (np) District Health 13 ROBERT McDONALD, Esq. ) Association of 14 Professional Engineers 15 & Geoscientists of 16 Saskatchewan 17 MICHAEL TOCHOR ) Department of Justice 18 L. M. SCHWANN (np) ) Saskatchewan 19 M. McDONALD (np) ) Environment and 20 Resource Management 21 R. G. HISCHEBETT ) Saskatchewan Health 22 R. E. PETRICH (np) ) Saskatchewan Municipal 23 Affairs and Housing 24 T. MICHAEL McDOUGALL (np) ) Saskatchewan Water 25 Corporation

1 SCOTT HOPLEY, Esq. ) Saskatchewan 2 MS. LESLIE BELLOC-PINDER (np) Environment Society and 3 Nature Saskatchewan 4 N.G. GABRIELSON, Q.C., Esq. ) Dr. L. Gerharde Benade 5 Dr. David Butler-Jones 6 and Dr. Eric Young 7 R.W. MITCHELL, Q.C., Esq.(np) )Canadian Union of 8 SANDRA G. MITCHELL, Ms. ) Public Employees, 9 Local 287 10 G.J. SCHARFSTEIN, Esq. ) On behalf of 427 11 individuals and 12 corporations affected 13 by the contaminated 14 potable water in North 15 Battleford 16 MYRA YUZAK, Ms. ) Dr. Andrea Ellis 17 18 19 20 21 22 23 24 25

1 TABLE OF CONTENTS 2 Page No. 3 List of Exhibits 5 4 PATRICK FLUNEY, Resumed 6 5 CROSS-EXAMINATION CONTINUED BY MR. GRANT SCHARFSTEIN 6 6 CROSS-EXAMINATION BY MR. KEN STEVENSON 11 7 CROSS-EXAMINATION BY MS. SANDRA MITCHELL 30 8 RE-DIRECT BY MR. JAMES RUSSELL 34 9 DR. ANDREA ELLIS, Affirmed 35 10 EXAMINATION-IN-CHIEF BY MR. CHRISTOPHER BOYCHUK 36 11 CROSS-EXAMINATION BY MR. TED PRIEL 136 12 CROSS-EXAMINATION BY MS. SANDRA MITCHELL 182 13 CROSS-EXAMINATION BY MR. NEIL GABRIELSON 187 14 CROSS-EXAMINATION BY MR. SCOTT HOPLEY 194 15 CROSS-EXAMINATION BY MR. MICHAEL TOCHOR 197 16 CROSS-EXAMINATION BY MR. GRANT SCHARFSTEIN 203 17 RE-DIRECT BY MR. CHRISTOPHER BOYCHUK 207 18 FRANK HOLLMANN, Sworn 213 19 EXAMINATION-IN-CHIEF BY MR. JAMES RUSSELL 215 20 21 22 Court Reporter's Certificate 267 23 24 25

1 LIST OF EXHIBITS 2 EXHIBIT NUMBER DESCRIPTION PAGE 3 C-11 for Letter from Saskatchewan Health to Mr. Bob 4 ident. Berry, director of Public Works and Utilities 5 at the City of North Battleford. And the other 6 document, also dated September 26th, 1994 7 from Ken Startup of Sask Health, North 8 Battleford Region, to the Provincial Lab 11 9 C-12 Binder entitled Health Canada, Dr. Andrea 10 Ellis 35 11 C-13 Binder referring to Frank Hollman, Peter Allen 12 and Judy Szuch. Tab 4 has been removed 215 13 14 15 16 17 18 19 20 21 22 23 24 25

1 --- Upon commencing at 9:30 a.m. 2 3 MR. COMMISSIONER: Yes, good morning, counsel 4 and perhaps we'll get underway at this point. 5 6 (BRIEF PAUSE) 7 8 MR. GRANT SCHARFSTEIN: Good morning, Mr. 9 Commissioner, in my haste to wrap up yesterday at 5:00 10 o'clock, there was one (1) or two (2) more questions that I 11 had overlooked to ask the witness, if I may this morning. 12 I was going to then save it for a couple of 13 other operators that will be called, but I realized that they 14 weren't employed at the plant at the time relevant to the two 15 (2) or three (3) more questions that I have. 16 So with your permission I'd like to just raise 17 one (1) more issue with the witness this morning in my cross- 18 examination. 19 MR. COMMISSIONER: All right. 20 MR. GRANT SCHARFSTEIN: Thank you. 21 MR. COMMISSIONER: Mr. Fluney... 22 23 (PATRICK FLUNEY, Resumed:) 24 25 CROSS-EXAMINATION CONTINUED BY MR. GRANT SCHARFSTEIN:

1 Q: Good morning, Mr. Fluney. 2 A: Good morning. 3 Q: I think your evidence you had indicated 4 that you weren't aware of what cryptosporidium was or 5 cryptosporidium in general, other than a couple of comments 6 Mr. Peter -- Peter Allen had thrown out while he was employed 7 at the plant; is that correct? 8 A: That's true. 9 Q: Do you recall any concerns or issues 10 raised about cryptosporidium at the North Battleford plants, 11 specifically in 1994, and specifically in September of 1994? 12 A: I can't recall anything being said to me 13 at all at that time about cryptosporidium or anything of that 14 nature. 15 Q: I have a copy of two (2) letters I'm 16 going to show you, and I have -- they're disclosed on the 17 disks that were given in this matter. 18 And I would like you to take a look at them, I 19 don't think I can introduce them through this witness unless 20 he's seen them before, and I'm not sure whether he has. 21 MR. COMMISSIONER: You could mark them for 22 identification if that's... 23 24 CONTINUED BY MR. GRANT SCHARFSTEIN: 25 Q: I'm showing a copy of two (2) letters to

1 you, they are found on -- for the benefit of other counsel, 2 on disk 2 of the document disks that we've received. The 3 City of North Battleford Document Box 1028, documents number 4 107615, which is the letter from Saskatchewan Health to Mr. 5 Bob Berry, director of Public Works and Utilities at the City 6 of North Battleford. 7 And the other document, also dated September 8 26th, 1994 from Ken Startup (phonetic) of Sask Health, North 9 Battleford Region, to the Provincial Lab is document number 10 107617. 11 And so those are the documents. Have you ever 12 seen these documents before, Mr. Fluney? 13 A: I don't recall them at -- at all. 14 Q: Yeah, I think the documents indicate that 15 there was a concern about cryptosporidium in 1994 and testing 16 was done? 17 A: That's right. 18 Q: As -- as an operator, you were never 19 advised of that or told of that by -- by anybody? 20 A: No. 21 Q: To your knowledge, was anyone or any of 22 the operators at the water treatment plant advised or told 23 about this concern of cryptosporidium in 1994? 24 A: I can't say what the other operators 25 would have been told, but I myself haven't -- haven't seen

1 these letters. 2 Q: And you were working at the -- at the 3 plant -- 4 A: Yes. 5 Q: -- in the relevant time in September of 6 1994; correct? 7 A: I don't know if I was actually there at 8 that time, without going through -- through the shift 9 schedule, but I was employed at the Plants Department, and I 10 probably would have been at the water plant. 11 MR. GRANT SCHARFSTEIN: If I could have 12 these two (2) documents entered for identification purposes, 13 and that's all the questions I have, Mr. Commissioner. 14 MR. COMMISSIONER: All right, thank you. Mr. 15 Russell, sorry -- 16 MR. TED PRIEL: Mr. Commissioner, I believe 17 my advice is to speak to the issue of -- of the introduction 18 of the documents. I think that they are already in by 19 agreement of counsel. 20 The agreement that we put in at the beginning 21 recorded all of these documents as exhibits, and it seems to 22 me as though they're already before you. 23 MR. COMMISSIONER: Okay, well that's a very 24 valid point. I hadn't considered -- do you agree with that, 25 Mr. Russell?

1 MR. JAMES RUSSELL: Well I don't think 2 they're in as exhibits, Mr. Commissioner -- 3 MR. COMMISSIONER: No. 4 MR. JAMES RUSSELL: -- I think -- 5 MR. COMMISSIONER: But they can go in as a 6 full exhibit now? 7 MR. JAMES RUSSELL: Well we do plan to 8 introduce them as a full exhibit later. 9 MR. COMMISSIONER: All right, well then 10 perhaps Mr. -- 11 MR. GRANT SCHARFSTEIN: We can leave it until 12 later for Mr. Russell to introduce, or we can put it as 13 identification at this stage and he can put it in as a full 14 exhibit, whichever the Commission prefers. 15 MR. COMMISSIONER: Yes. To the extent the 16 witness has not particularly identified the document, and I 17 take your point, Mr. Priel. 18 But perhaps for -- we'll leave it as a C-11 19 for identification at this point, and then if Mr. Russell or 20 some other witness will authenticate it later on. 21 MR. GRANT SCHARFSTEIN: That's fine. 22 MR. COMMISSIONER: Thank you. It's being 23 introduced for identification simply to make the point I 24 suppose that this witness didn't become aware of it, that's 25 all.

1 MR. GRANT SCHARFSTEIN: Correct. 2 3 --- EXHIBIT C-11 FOR IDENTIFICATION: Letter from 4 Saskatchewan Health to Mr. Bob Berry, 5 director of Public Works and Utilities at 6 the City of North Battleford. 7 And the other document, also dated 8 September 26th, 1994 from Ken Startup of 9 Sask Health, North Battleford Region, to 10 the Provincial Lab. 11 12 MR. COMMISSIONER: All right. All right, Mr. 13 Stevenson and then Ms. Mitchell, I believe, right? Is that 14 right? 15 16 (BRIEF PAUSE) 17 18 MR. KEN STEVENSON: Thank you, Mr. 19 Commissioner. 20 21 CROSS-EXAMINATION BY MR. KEN STEVENSON: 22 Q: Good morning, Mr. Fluney. 23 A: Good morning. 24 Q: I just have a few questions for you, Pat. 25 Mr. Scharfstein just asked you some questions concerning

1 matters which were not brought to your attention. I take it 2 that at no time in 1994 were you advised that there was in 3 fact a positive, or that this was negative -- that these 4 results were actually negative when they were tested? 5 A: I -- I was never advised of anything -- 6 Q: Okay. 7 A: -- at that time. I would have remembered 8 if I would have been informed of it. 9 Q: Right. And it's my understanding and the 10 evidence will establish that these, in fact, were negative 11 results on that test -- 12 A: Okay. 13 Q: -- and that may explain why you weren't 14 informed; is that -- 15 A: That could be. 16 Q: You were asked some questions yesterday 17 concerning record-keeping and records which were kept and in 18 the course of it you were referred to some computer generated 19 plant logs and it's my understanding that the plant computer 20 recorded many things and many other items and chemicals, 21 other than are shown in the plant log record which was before 22 you -- 23 A: Yes. 24 Q: -- and which you referred to yesterday. 25 A: Yes.

1 Q: I wonder if I might have that, and this 2 was an exhibit through Mr. McDonald. A number of other plant 3 records came in at that time and I'd just like to have them 4 referred to if I might. 5 6 (BRIEF PAUSE) 7 8 And here we have a portion of the records 9 which were maintained and I'd just like to go through with 10 you, Mr. Fluney, if I might, as to whether or not you were 11 familiar that these records were produced or were maintained 12 by the computer. 13 MR. COMMISSIONER: Well, to the extent we're 14 referring to a record, we're going to have to use an exhibit 15 number and where it appears in exhibit number, otherwise the 16 transcript will not make much sense. 17 MR. KEN STEVENSON: Right, and Mr. McDonald's 18 exhibit I believe was -- 19 MR. COMMISSIONER: C-3 -- 20 MR. KEN STEVENSON: -- C-3, tab 4. 21 MR. COMMISSIONER: C-3, tab 4. So it was 22 part of the PowerPoint presentation is what it amounts to 23 then, okay. 24 MR. KEN STEVENSON: No, it was a separate 25 computer disk --

1 MR. COMMISSIONER: Okay. 2 MR. KEN STEVENSON: -- of records. 3 MR. COMMISSIONER: All right, that makes 4 sense. There is a disk here so -- 5 MR. KEN STEVENSON: Yes. 6 MR. COMMISSIONER: So, anyway, we're 7 referring to a document that -- well, I'll let you identify 8 it, Mr. Stevenson or Mr. Fluney can for the record please. 9 MR. KEN STEVENSON: Right. 10 11 CONTINUED BY MR. KEN STEVENSON: 12 Q: Mr. Fluney, as I understand it, this is a 13 printout of the information entered into and stored on the 14 computer maintained at the Number 2 Water Treatment Plant? 15 A: Yes. 16 Q: Okay. And you're familiar with that 17 record-keeping? 18 A: Yes. 19 Q: And, just so we might touch the 20 parameters which were recorded so there's no uncertainty as 21 to what records the city was keeping, when I look at it, we 22 see a date and a time and that time would indicate what, Mr. 23 Fluney? 24 A: The time taken from the log and then 25 transferred over into -- into this record here. It should

1 have been the time that the computer recorded the figures. 2 It could be on every fifteen (15) minutes or on the half-hour 3 or on the hour. 4 Q: So whatever time shows there is the time 5 the information was entered on the computer? 6 A: That's right. 7 Q: And the -- then we have a column for the 8 operator and that would identify who was making -- 9 A: The operator number, yes. 10 Q: Yes. And then we have a TW free 11 chlorine. Is that treated water free chlorine? 12 A: Yes, it is. 13 Q: And the next, we have a treated water 14 total chlorine entry? 15 A: Yes. 16 Q: And the ALM setting is the alum setting? 17 A: The setting for the alum, yes. 18 Q: Now, how does the setting vary from the 19 next column, which is alum milligrams per litre? 20 A: The alum setting is the setting that is 21 on the Bailey panel and that is done on a timer from zero (0) 22 to sixty (60) seconds and as a certain amount of cubic metres 23 of water go through, it'll kick this -- kick the timer on, 24 it'll run for seven -- seven (7) seconds and then shut off. 25 Q: So what we see there records seconds?

1 A: That's right. 2 Q: Okay. And the next column, the alum 3 milligrams per litre, would show then the concentration 4 level? 5 A: The -- the dosage level, yes. 6 Q: Dosage level, okay. And which is the 7 particularly important one (1) at the end of the day, is that 8 the dosage level or the setting? 9 A: Is -- the dosage is -- is more important. 10 They both correspond, they're the same thing. 11 Q: Okay, thank you. And the -- the next 12 column then, what does it record? 13 A: Is the alum pump in millilitres per 14 second, in -- in millilitres and if the pump ran for the full 15 minute it would pump thirteen hundred (1,300) mls. 16 Q: And if was running only the seven (7) 17 seconds -- 18 A: Seven (7) seconds it would be cut down to 19 your -- your other readings. 20 Q: Thank you. And the next column, is that 21 aluminex? 22 A: Is the aluminex setting. On the Bailey 23 panel. And then your next one is your milligrams per litre. 24 Q: Okay. And the next column? 25 A: Is your aluminex pumps in mls if it ran

1 for sixty (60) seconds. 2 Q: And the next column would be the polymer 3 milligrams per litre, is that -- ? 4 A: That's right. 5 Q: Okay. And then the -- the poly -- 6 A: The poly pump, if it ran for a full 7 minute would give you six hundred and forty-five (645) mls. 8 And then the potassium permanganate in parts per million or 9 milligrams per litre. The temperature of the water in the-- 10 in the permanganate feed line. 11 Q: And there was one (1) just before that, I 12 believe there was a lime setting -- lime entries? 13 A: Yes, and that's a setting on the lime 14 machine, right on the lime machine. And that would give us 15 our -- then our milligrams per litre. 16 Q: Okay. 17 MR. COMMISSIONER: Again, that is seconds? 18 THE WITNESS: That is in seconds. No, it's 19 not. It is a -- it's just a setting -- a dial setting on the 20 front of the machine. It constantly turns. There's a 21 setting on it from I think zero (0) to, if I'm not mistaken, 22 it's thirty (30). 23 And as we need more lime, we turn it up, turns 24 the auger inside it faster. 25

1 CONTINUED BY MR. KEN STEVENSON: 2 Q: And then after the permanganate, we're 3 into the chlorine settings? 4 A: Chlorine settings on the rotameter and 5 that is done -- the setting would be twenty (20) pounds of 6 chlorine in twenty-four (24) hours. And then we'd have our 7 parts per million of chlorine. 8 Q: Okay. And then total -- 9 A: Total -- 10 Q: -- cubic metres? 11 A: -- cubic metres. 12 Q: What does that record? 13 A: That I really can't say. I don't know. 14 Q: Okay. It shows a zero (0) entry on it. 15 A: It shows zero (0) -- I -- 16 Q: And then it shows a shut down time? 17 A: Shut down. 18 Q: So that these are records which are 19 maintained by the operators throughout the day each and every 20 day when the plant is operating? 21 A: No. The records that we keep and that we 22 punch into, is on the plant log. And these figures are then 23 taken from there, not by ourselves, by the computer, and 24 inserted onto this sheet, there. It's something that's done 25 automatically. We don't actually punch these figures in.

1 Q: Right. But you enter them into 2 another -- 3 A: Into the first part or the main screen 4 for the plant log. 5 Q: Right. Okay. And there were some 6 handwritten records which were referred to -- 7 A: That's right. 8 Q: -- and those are written by the operator 9 at the time? 10 A: Those are written by the operator as he 11 does his tests and then taken from there and put into the 12 computer. 13 Q: Okay. And in your recording these 14 handwritten notes, I take it that you would use your best 15 endeavours to ensure that the recordings were accurate? 16 A: Yes. 17 Q: And would reflect the actual results 18 which were observed? 19 A: What we would do is take our results from 20 the handwritten sheets and enter them into the computer, yes. 21 Q: And to your knowledge any entries that 22 you personally would have made, were those accurate? 23 A: Yes. 24 Q: There was some discussion in your 25 evidence concerning the absence of a plant's foreman after

1 Me. Katzell's departure -- or Katzell's departure. 2 A: Katzell's -- yes. 3 Q: Were you aware of what attempts the city 4 was making in the months of November or December, to hire a 5 replacement manager or foreman for that position? 6 A: I know that they had a posting out for 7 one (1), yes. 8 Q: And were you aware of whether or not in 9 early January they had offered the position to a prospective 10 employee? 11 A: I heard that they had, yes. 12 Q: Okay. So it was your information that 13 the city wasn't simply ignoring filling that position, that 14 they were actively recruiting? 15 A: They were trying to recruit, yes. 16 Q: Now you've touched upon the maintenance, 17 which was undertaken for the solids contact unit in March of 18 2001. And as I understand it, that's a procedure which had 19 been followed previously and was part of regular periodic 20 maintenance? 21 A: Yes. 22 Q: And in addition to that, there was a need 23 to do an inspection of a crack which had been observed on the 24 last maintenance? 25 A: Yes.

1 Q: And that for that reason it became 2 necessary to completely clean the solids contact unit? 3 A: Yes. 4 Q: And on other occasions would the solids 5 contact be cleaned to the same extent as it was on this 6 occasion? 7 A: I think a lot of that would depend on how 8 pushed we were for time to get it finished. Some of the 9 other times we would take it down -- take the sediment out of 10 the bottom, there would be a little bit left, it wasn't 11 cleaned to the same extent as when we were checking for the 12 crack. 13 Q: Do you know the capacity -- how many 14 gallons this solids contact unit would hold? 15 A: Not off hand. 16 Q: No. It's my information that it may be 17 in the range of a hundred and fifty thousand (150,000) 18 gallons? 19 A: That could very well be. 20 Q: There was also discussion about whether 21 or not floc or the sludge could be saved. Was there any 22 method in the construction as it existed in March of 01, 23 where you -- whereby you could save some of the sludge or 24 floc materials? 25 A: No, there was no provision to save any of

1 the floc into any of the tanks or any temporary storage. 2 There was no provision for that. 3 As far as saving the sludge, the sludge is 4 something that you wouldn't want to save. It's river silt, 5 it's dead chemical, it's -- it's used up. That is what you 6 would want to get rid of regardless. 7 And as you drain down your solids contact, the 8 first thing that you do lose is your floc. 9 Q: So in -- if you had a method for saving 10 floc and given the capacity of the solids contact unit, you 11 would have to save a substantial amount of -- 12 A: Yes. 13 Q: -- materials? 14 A: Yes, we would. 15 Q: Yeah, in order for it to have any 16 significant or positive impact? 17 A: I'm not sure of how much we would have to 18 save to reseed the solids contact, it think it would be a -- 19 it would probably be a fair amount. 20 Q: And in March of -- of 2001, the people -- 21 the operators involved in doing this maintenance on the 22 solids contact unit, as I understand it, were all 23 experienced, qualified plant operators? 24 A: Yes. 25 Q: And those who operated the plant after

1 the startup of the operations on March 20, through the 2 relevant period, again were all qualified operators? 3 A: I would have to disagree with that. The 4 night that it was taken down an assistant plants operator 5 operated the plant. 6 Q: Okay. Other than that one (1) 7 occasion -- 8 A: There -- there may have been other times 9 when they operated. It would not show in the plant log as 10 the names were not changed, the operator numbers were not 11 changed. 12 Q: Okay. Do you know if, other than that 13 one (1) occasion, either of these two (2) junior operators 14 operated the plant on their own during the relevant period? 15 A: I can't say offhand. 16 Q: Okay. And, if we looked at the plant 17 operating records on March 20, if you might go to that, and 18 it's Exhibit -- is it C-5, I don't have it in front of me; 19 the computer printout, C-7 if you have it in front of you. 20 If you go to the record for March 20 -- 21 MR. COMMISSIONER: It would be under tab 4 in 22 C-7. 23 24 (BRIEF PAUSE) 25

1 CONTINUED BY MR. KEN STEVENSON: 2 Q: If you look at the start-up of the plant 3 on that occasion -- 4 A: Yes. 5 Q: -- can you tell me what time the plant 6 started? 7 A: At 19:27. 8 Q: And at what time was it shut down? 9 A: It was shut down at 20:23. 10 Q: So we had it running or fifty-six (56) 11 minutes; is that -- 12 A: Okay, yes. 13 Q: Would that be -- that be fair to say? 14 A: That would be fair to say, yes. 15 Q: Right. So it -- it ran only very briefly 16 by that other junior operator, if I can put it that way, on 17 that occasion? 18 A: That's right. He would have operated the 19 plant up 'til that time, but pumped it to waste. 20 Q: Right. 21 A: Yes. 22 Q: And, from my review of the records and, 23 if it does disclose that someone other than one (1) of the 24 senior qualified operators operated the plant during the 25 material time, it appears from reviewing the records that the

1 plant was operated in a consistent manner in terms of 2 chemical levels, turbidity levels that were being generated; 3 is that fair to say? 4 A: Yes. Yes. 5 Q: Okay. Now, when the solids contact unit 6 was down, I believe you touched on this in your evidence, you 7 paid fairly close attention to the filters and the operation 8 of the filters; is that correct? 9 A: Yes. 10 Q: And why was that, Mr. Fluney? 11 A: When -- to pump to waste, we have to 12 drain the filters down and leave them idle while we pump to 13 waste, when we have a chlorine residual that is high and 14 there are chemicals in it, then we can refill, take through 15 the filters and into the clear well afterwards. 16 Q: And, while the solids contact was down 17 and you weren't getting any settling from it, you were still 18 running water through the filters? 19 A: We are running water through the filters, 20 yes. 21 Q: And what is your understanding as to what 22 part in the water treatment these filters were then playing? 23 A: They were playing a major part. 24 Q: And you referred to the white floc which 25 was seen in the solids contact unit, in the samples; is that

1 fair? 2 A: Yes. 3 Q: And I take it the filters were removing 4 that from the water? 5 A: Yes, they were. 6 Q: And you were getting a turbidity level 7 within the clear well which was acceptable; is that correct? 8 A: Yes. 9 Q: And were you, during the time you were 10 operating the plant, monitoring that turbidity level in the 11 clear well water with close attention? 12 A: Yes. 13 Q: And were you satisfied that the water 14 produced during your operation, satisfied the operational 15 requirements, namely less than one (1) NTU of turbidity? 16 A: Yes. 17 Q: And during the time you were operating 18 the plant, were you satisfied that the residual chlorine 19 levels met the requirements for operation? 20 A: Yes. 21 Q: Both total and free? 22 A: Yes. 23 Q: So that during this relevant period, 24 while there may not have been settling, and you've talked 25 about significance of settling, you were still producing

1 water which was within the objective and guidelines of the 2 North Battleford plant. Is that correct? 3 A: Yes. 4 Q: And at that time, the parameter which you 5 had for measuring in part the water quality, other than 6 disinfection, was the turbidimeter? 7 A: Yes. 8 Q: And the need to maintain water below one 9 point zero (1.0) NTU's? 10 A: Yes. We tried to get that water as clean 11 as we could, yes. 12 Q: Right. As clean as you could and -- and 13 you -- 14 A: It -- 15 Q: -- did very well through most of the 16 period. 17 A: That's right. 18 Q: Right. And as I looked at the records, 19 you were getting turbidity of less than two (2) after the 20 solids contact unit was down, up until March 26th? 21 A: Point two (.2)? 22 Q: Point two (.2), I'm sorry. 23 A: Yes. 24 Q: Not two point (2.) -- zero point two 25 (0.2).

1 A: Yes. 2 Q: Thank you. And that would be fairly 3 consistent within the range of the turbidity which was being 4 produced before the solids contact unit was taken down? 5 A: Yes. 6 Q: So in that time frame, and you've used 7 the word "decent" water, I take it, or is it right, Mr. 8 Fluney, that you were producing what you considered to be 9 safe water? 10 A: Yes. 11 Q: And did you consider it to be quality 12 water? 13 A: Yes. 14 Q: Now as I understand it, since this 15 incident in -- since March, April of '01, you have been 16 operating when the -- in order to remove the boil water 17 order, the city has been required to operate Water Treatment 18 Plant number 2 under different parameters for turbidity? 19 A: Yes. 20 Q: And at the present time what are the 21 requirements for turbidity on this plant? 22 A: The turbidity, coming out of the filters 23 has to be zero point three (0.3) before it's put online. 24 Q: Okay. So this is zero point three (0.3) 25 versus the prior operating conditions of one point zero

1 (1.0)? 2 A: Of one point zero (1.0), yes. 3 Q: And as I understand it, when the boil 4 water order came off and put the water back on, there was 5 also installed particle counters on the filters, is that 6 correct? 7 A: Yes. 8 Q: Okay. And these particle counters would 9 in effect be a new introduction of a new parameter for 10 monitoring the water? 11 A: Yes. Can I just -- ? 12 Q: Sure. 13 A: Okay. The particle counters were 14 installed. The only reservation that I have with them is 15 that the operators were not instructed of where we should be, 16 how they work and any maintenance on them. And we have had 17 trouble with them. 18 Q: Okay. I appreciate that but there is a 19 new -- 20 A: Yes. 21 Q: -- you're moving to a new parameter -- 22 A: Yes. 23 Q: -- if I can put it that way? 24 A: Yes. 25 Q: Okay. And as I understand it, it's also

1 in the -- in the cards that you'll be moving to a new barrier 2 of treatment? 3 A: Yes. 4 Q: Do you understand that? 5 A: Yes. 6 Q: And that'll either be UV or ozone, is 7 that correct? 8 A: Yes. 9 10 (BRIEF PAUSE) 11 12 Q: But going backwards, the parameter which 13 existed that you could use to measure the clarity and to 14 having success of having taken particles out of the water was 15 turbidity? 16 A: Yes. 17 Q: That's all, thank you, Mr. Fluney. 18 MR. COMMISSIONER: Thank you. Ms. 19 Mitchell...? 20 MS. SANDRA MITCHELL: Thank you, Mr. 21 Commissioner. 22 23 CROSS-EXAMINATION BY MS. SANDRA MITCHELL: 24 Q: I just have two (2) areas of questioning, 25 Mr. Fluney, the first one (1) has to do with the aluminex,

1 and towards that end I wonder if I might ask that that 2 Exhibit titled C-3 at tab 4, that Mr. Stevenson was referring 3 to, be brought up on the screen. 4 5 (BRIEF PAUSE) 6 7 MR. COMMISSIONER: Is that the one (1) you 8 wished, or -- 9 MS. SANDRA MITCHELL: That -- no, that's the 10 previous one (1) that was there before. 11 MR. COMMISSIONER: Yes, I believe -- 12 MS. SANDRA MITCHELL: Yes. 13 MR. COMMISSIONER: -- the March 20th, C-3, 14 tab -- 15 MS. SANDRA MITCHELL: Yeah, that -- that's 16 it, it's just too much over to the side. 17 MR. COMMISSIONER: Oh, I see, all right. 18 MS. SANDRA MITCHELL: There. No, it's the -- 19 yeah, it's -- I'm referring to the column at the very right 20 of the -- there it is. 21 Okay, there it is. 22 23 CONTINUED BY MS. SANDRA MITCHELL: 24 Q: Mr. Fluney, it's now the third column 25 over from the right, it's the aluminex setting.

1 A: Yes. 2 Q: Do you see that column? 3 A: Yes, I do. 4 Q: And I see that it's recorded, eleven 5 (11), eleven (11), eleven (11) and so on, and then it 6 switches to zero (0). And I wonder what the explanation for 7 that is. Did you -- did you add aluminex to the water all 8 year round? 9 A: No, we didn't. The aluminex was got -- 10 was purchased and brought in to be used through the busy 11 season. 12 Q: And that was in the summer you mean? 13 A: That was in the summer during peak 14 demand. And we would bring in four (4) or five (5) 15 containers, and then it would be used and until it ran out, 16 and then no more would be purchased until the next year. 17 Q: And about when would it run out? 18 A: Towards late fall. 19 Q: And whose decision was that not to 20 purchase more or to use it only for that busy period? 21 A: That was the foreman's decision. 22 Q: And Mr. Stevenson had asked you about 23 computer records and he referred to C-7, and I don't need to 24 have that brought up. But on that point of computer records, 25 who installed the computer program that is in existence at

1 the plant? 2 A: One (1) of the previous operators. 3 Q: And what was that person's name? 4 A: It was Lenn Holliday. 5 Q: And he's no longer there? 6 A: No, he retired. 7 Q: And how did that computer program work? 8 And I -- I don't need you to explain the logistics of it to a 9 luddite like me, but I need to know whether or not you had 10 confidence that it -- the records were always accurate or 11 that the program always worked? 12 A: The program did have some glitches in it. 13 Sometimes it would skip out on us, it wasn't fool proof. 14 That's why we placed a big emphasis on our handwritten 15 records. 16 Q: I have no further questions. I know this 17 has been difficult for you and I want to thank you very much 18 for three (3) days of evidence. 19 A: Thank you. 20 MR. COMMISSIONER: All right, Mr. Russell, do 21 you have any re-examination? 22 MR. JAMES RUSSELL: Mr. Commissioner, just 23 one (1) quick point as there may be a slight contradiction on 24 the record, which I would just like to have Mr. Fluney 25 clarify.

1 RE-DIRECT BY MR. JAMES RUSSELL: 2 Q: I believe, Mr. Fluney, when you were 3 discussing with Mr. Stevenson Exhibit C-7, tab 4, from March 4 20th, this is the -- the day of the cleaning of the solids 5 contact unit. 6 My understanding was the evidence you gave was 7 that these -- the entries made on March the 20th, 2001 show 8 that the water was being pumped to waste at this time. Is 9 that what you said? 10 A: The water was being pumped -- pumped to 11 waste until 19:27. There's no computer record of that. 12 Q: I see. But on this particular day the 13 water -- I mean it does show that we have sixty-six five 14 hundred and forty-two (66,542) gallons treated that day. 15 A: That's right. 16 Q: Okay. So you weren't -- you weren't 17 saying that this was pumping to waste, it was pumped to waste 18 prior to this record? 19 A: It was pumped to waste prior to that and 20 then it was put into the clear well at this time. 21 MR. JAMES RUSSELL: Thank you, Mr. Fluney. 22 Thank you, Mr. Commissioner, no further questions. 23 MR. COMMISSIONER: All right, thank you. 24 Well, thank you, Mr. Fluney, you've had a long stretch as a 25 witness and you're free to step down and free to go.

1 2 (WITNESS STANDS DOWN) 3 4 MR. CHRISTOPHER BOYCHUK: Good morning, Mr. 5 Commissioner, our next witness is Dr. Andrea Ellis. Andrea, 6 if you could... 7 8 ANDREA GERTRUDE ELLIS, Affirmed: 9 10 MR. CHRISTOPHER BOYCHUK: Then, Mr. 11 Commissioner, we have an exhibit binder prepared for this 12 witness that, if -- with your permission, I'll file. 13 MR. COMMISSIONER: All right. A binder 14 headed up Health Canada, Dr. Andrea Ellis, will be C-12, I 15 believe; is that right? 16 17 --- EXHIBIT NO. C-12: Binder entitled Health Canada, 18 Dr. Andrea Ellis 19 20 MR. CHRISTOPHER BOYCHUK: And, just for the 21 benefit of counsel, one (1) of the tabs in that binder was 22 removed this morning, there was -- some counsel indicated 23 that they may have a problem doing cross-examination so, for 24 the information of counsel, tab number 4 -- it is not in your 25 binder, Mr. Commissioner -- has been removed, we'll be

1 entering that through another witness. 2 And, as a consequence, one (1) of the slides 3 in Dr. Ellis' PowerPoint will change and we'll get to that 4 and we'll identify it and we'll make sure that the -- there's 5 a proper replacement put in the exhibit binder; if that's 6 acceptable. 7 MR. COMMISSIONER: Yes, that's fine. 8 MR. CHRISTOPHER BOYCHUK: Okay. 9 10 EXAMINATION-IN-CHIEF BY MR. CHRISTOPHER BOYCHUK: 11 Q: Good morning, Dr. Ellis. I understand 12 you are a Doctor of veterinary medicine? 13 A: That's correct. 14 Q: And that you obtained your doctorate -- 15 or your Doctorate of Veterinary Medicine in 1989 from the 16 University of Guelph? 17 A: That's right. 18 Q: And that also you have a Masters in 19 Science and Epidemiology? 20 A: That's correct. 21 Q: And that was obtained, again, from the 22 University of Guelph in 1993? 23 A: That's right. 24 Q: And from 1996 -- or 1994 to 1996 I 25 understand you've been working as a field epidemiologist with

1 Health Canada? 2 A: That's correct. 3 Q: And that in 1996 to 1999 you were the 4 senior epidemiologist at the Foodborne and Enteric Disease 5 Division at Health Canada? 6 A: That's right. 7 Q: And from 1999 to present you are the 8 Section Head of the Outbreak Response and Issues Management 9 Division of the Enteric Foodborne and Waterborne Disease 10 Division of Health Canada? 11 A: Yeah, it's actually the Outbreak Response 12 Issues -- 13 Q: Oh, sorry. 14 A: -- Management Section of the Division. 15 Q: Okay -- okay, thank you. And, as an 16 epidemiologist, you have been involved in -- one (1) of your 17 functions is outbreak investigation? 18 A: That's right. 19 Q: And the epidemiological investigation 20 of -- of enteric disease outbreak? 21 A: That's right. 22 Q: Foodborne and waterborne? 23 A: That's correct. 24 Q: And that you have been involved in a 25 number of investigations, including an international team

1 that investigated a foodborne outbreak of cyclospororiosis 2 (phonetic), if I've pronounced that correctly? 3 A: Yes, it's another parasite. 4 Q: Right. And, as well, outbreak 5 investigations involving salmonella, shigella; correct? 6 A: Yes. 7 Q: And that you are also involved in a 8 waterborne outbreak of Norwalk virus in the Yukon in 1995? 9 A: That's right. 10 Q: And most recently you led the Health 11 Canada team that conducted the epidemiological investigation 12 of the outbreak of E.coli and campylobacter in Walkerton last 13 year in May? 14 A: That's right. 15 Q: And that, in January of this year, you 16 presented as an expert the results of that epidemiological 17 investigation to the Walkerton Inquiry? 18 A: That's right. 19 Q: And I also understand that, like 20 Walkerton, you -- or Health Canada, your -- your department 21 was invited to assist in an epidemial -- epidemiological 22 investigation of the outbreak in Battleford that is the 23 subject of this Inquiry? 24 A: That's correct. 25 Q: And that you have prepared a report of

1 that outbreak? 2 A: Yes, we have. 3 Q: And that that report is at tab 2 of the 4 binder that's just been exhibited? 5 A: Yes. 6 Q: Okay. And I also have your CV at tab 1 7 of the binder, together with the CV's of Dr. Aramini and Dr. 8 Stirling? 9 A: Yes. 10 Q: And I understand that Dr. Aramini and Dr. 11 Stirling are also both epidemiologists, employed with Health 12 Canada? 13 A: That's right. 14 Q: And they were actually on site in 15 Battleford, involved in the conduct of the investigation? 16 A: That's correct. They were out doing the 17 field investigations. 18 Q: Okay. They were the field people on 19 the -- on the investigation. And you, yourself, were you 20 physically in Battleford during the course of the 21 investigation? 22 A: I wasn't here during that time but I was 23 in constant contact with them and participated in all of the 24 health unit conference calls for quite a period of time. So 25 I was very involved in the supervision of both those people.

1 Q: Okay. And I understand you would have 2 been the team leader -- 3 A: That's correct. 4 Q: -- in the investigation? What I'd ask, I 5 understand that you've prepared a PowerPoint presentation in 6 order to summarize the report for us. So what I'd ask you to 7 do is if you could proceed with your PowerPoint and what I 8 would just do is from time to time, if I have any questions 9 arising out of the PowerPoint, I will ask you? 10 A: Okay. I'll quickly get a drink. 11 I do appreciate being able to provide this 12 information in PowerPoint format. It will certainly, I hope, 13 make it easier for everybody. And I want to just make it 14 clear, I will be limiting the scope of my presentation, as 15 well as what the report is limited to, to the activities in 16 which Health Canada was directly involved. So our report 17 starts when we arrived on the ground, it doesn't go before 18 that. 19 And so just to move into that -- and this 20 report, again, is a report that we've provided to the -- the 21 Province of Saskatchewan and to the Health Department here 22 in -- in the Battleford. 23 Q: You mean the Battleford's health 24 district? 25 A: That's correct. Just before I get into

1 the -- the meat of the presentation, I want to make it clear, 2 in terms of what Health Canada's mandate is in these kinds of 3 investigations. And basically we -- we only become involved 4 in a local or a provincial outbreak investigation upon 5 invitation from the province. 6 The invitation has to come to us through the 7 province. And once we are were, we report to the Medical 8 Officer in charge. And in this case -- so Dr. Stirling and 9 Dr. Aramini, when they were here, they were reporting to Dr. 10 Benade. In addition, the Province of Saskatchewan, Dr. Eric 11 Young (phonetic) was very much involved as well in that -- 12 that group and so we were reporting information directly to 13 him as well. 14 Just to give you a little bit better idea 15 of -- of our -- of my section, within the division of Enteric 16 Foodborne and Waterborne Diseases. Yes, we do conduct 17 outbreak investigations in these areas. In addition, we'll 18 provide expertise to provincial and local officials upon 19 request. We're often being phoned about outbreaks of -- of 20 any number of things that occur, just to get some expertise 21 that they might draw upon if they don't want us to directly 22 become involved in terms of the field investigation. 23 If an outbreak in fact is national in scope, 24 which happens a fair amount, and particularly with foodborne 25 situations, then we'll be coordinating that national effort.

1 So it might involve two (2) or three (3) provinces or else it 2 might involve every province and territory. 3 And in addition, actually I should add, that 4 we also will coordinate on international investigations where 5 Canada and the U.S. are primarily the one's involved. We 6 also conduct surveillance for enteric disease outbreaks. 7 Q: And I understand that Health Canada has a 8 national Enteric Disease Surveillance Program, is that 9 correct? 10 A: That's correct. We have a laboratory in 11 Winnipeg which is a national reference lab for enteric 12 pathogens. And they receive information on a weekly basis on 13 all enteric organisms that are reported in all of the labs 14 across Canada. 15 So we have weekly information that comes to us 16 and we've also been developing a web based alert system as 17 well as a summary reporting system for enteric outbreaks. 18 Q: And just on that point, is there a -- a 19 uniform list of diseases that are reportable across Canada or 20 is it a patchwork depending on the -- the various provinces 21 own regulations in terms of what they have decided is -- 22 A: No. 23 Q: -- reportable. 24 A: We do have a list of -- of reportable 25 diseases in Canada and -- and among them are things that

1 would be, what we call, enteric pathogens. Things that 2 affect your gastro intestinal tract and cause diarrhea, such 3 as cryptosporidium. 4 Those are -- we do have national notifiable 5 diseases, but then each province has their own, and they're 6 basically the same diseases. We will have some minor 7 variations in some provinces, but we do have ones that we do 8 request the provinces, it's by request, it's not a 9 regulation, that they report to us on a regular basis. 10 Q: So it's a voluntary program; correct? 11 A: Correct. 12 Q: The other thing that I wanted to ask you 13 is do you know how long that cryptosporidium has been on 14 Health Canada's National -- or part of Health Canada's 15 National Surveillance Program? 16 A: Yes, it became nationally notifiable in 17 2000 -- January 2000. 18 Q: Thank you. Okay, those are -- 19 A: Just to give you an idea of the expertise 20 that we brought through our team, we -- this included -- this 21 has already been mentioned, Phil Dapuniar (phonetic) just for 22 expertise and outbreak investigation, specifically we also 23 have some expertise in waterborne disease surveillance, more 24 specifically Dr. Aramini, for example, has done quite a bit 25 of work in looking at waterborne diseases in Canada, and we

1 have some ongoing research projects. 2 Also looking more specifically at the 3 epidemiology of cryptosporidiosis. 4 We also had a medical geographer who helped us 5 to do some mapping, and a number of statisticians as well, 6 who -- who did some of the analysis. 7 I'm sorry. Just to give you the names of 8 everybody, we've already mentioned Dr. Rob Stirling, Dr. Jeff 9 Aramini, and we've mentioned Rob Stirling is part of the 10 Field Epidemiology Training Program. 11 This is a two (2) year training program that 12 Health Canada has that I went through and a number of other 13 people who do this kind of work have been through that 14 program. 15 Jillian Lim is a statistician with us, who did 16 some of this work. Rob Meyers is our medical geographer, 17 Manon Fleury is another statistician, and Dr. Denise Werker, 18 up until October 1st, was the Director of the Field 19 Epidemiology Training Program. 20 So it was primarily Dr. Werker and myself who 21 were supervising Dr. Aramini and Dr. Stirling while they were 22 here, and then I continued on once we got to a certain point, 23 in being the main -- the main coordinator of -- of the 24 activities. 25 Q: Okay.

1 A: I just want to acknowledge as well, that 2 certainly what I'm saying, that this is -- these are Health 3 Canada's activities, none of these activities could have been 4 carried out without a number of different organizations 5 providing us with information, doing some of the data 6 collection, providing input on our study design and 7 questionnaire design, that kind of thing. 8 And that included the -- the Battleford 9 District Health Unit, Sask -- Saskatchewan Health, the other 10 Health Districts in the First Nations in Saskatchewan, the 11 municipal officials, Public Works employees and both the City 12 of North Battleford and the Town of Battleford. 13 People from SERM. We also had the -- the 14 Centre for Disease Control in British Columbia involved in 15 doing some further work on the -- the oocysts from patients. 16 And we also had some input from the pharmacies. 17 All of the work we did though, was under the 18 jurisdictional authority of both the province and the health 19 unit again. So when we were accessing this kind of 20 information, it was because we were working on behalf of the 21 province and the -- the local health authorities. 22 Q: Okay, and can I -- with the 23 acknowledgements, can you give us a bit of an idea 24 specifically what kind of information or assistance you were 25 getting from the Battleford's District Health Unit?

1 A: The Battleford's District Health Unit 2 were involved in the data collection, in terms of people 3 phoning in and providing and collecting that information from 4 them. 5 They also were directly involved in 6 administering a community survey. The Health Inspectors were 7 involved in -- in taking Dr. Aramini and Dr. Stirling around 8 to give them a better sense of the -- the waterworks in both 9 the city and the town. 10 And certainly Dr. Bonade was -- was very 11 helpful in trying -- also adding input to our -- our 12 epidemiologic study, in terms of the design and giving us a 13 sense of what had been going on there before we arrived. 14 Q: Okay. And with Dr. Bonade we'll get to 15 some of the design of the questionnaires, but that would be 16 one (1) area he would be providing input on in the design of 17 the various information into the forms that you were using in 18 questionnaires? 19 A: We would have saw input from -- from Dr. 20 Bonade, as well as people at the Sask Health, specifically 21 Dr. Eric Young and Ms. Helen Bengura. 22 Q: And I -- and Ms. Bengura is the 23 Provincial Epidemiologist for Saskatchewan? 24 A: She's actually the Communicable Disease 25 Epidemiologist --

1 Q: Sorry, okay. 2 A: -- yeah. What I didn't point out on a 3 previous slide is that two (2) areas of expertise that we did 4 not have directly in our team included our laboratory for 5 example, our national laboratory was not involved in any of 6 the testing. 7 So all of the laboratory work that was done 8 was done either by local labs, the provincial lab or, as I 9 mentioned, the -- the lab in British Columbia that did some 10 further work. 11 Q: So that would be one (1) of the roles of 12 Saskatchewan Health, their orovincial lab would have been 13 providing the -- the laboratory work when a large part of it 14 was done through the provincial lab of Saskatchewan Health? 15 A: That's right. That's correct. In 16 addition, we also -- we don't have any engineers in our unit, 17 for example, so we just wanted to get information with 18 regards to water quality parameters, but we -- in terms of 19 any specific engineering type questions, that was something 20 that we had to rely on others for. 21 Q: And, with the City of North Battleford, 22 can you tell us a little bit of the -- of the assistance that 23 they provided in terms of the -- the investigation? 24 A: They were -- they were able to assist in 25 taking -- taking Dr. Aramini specifically through the plant

1 to give an idea of the operations, providing us information 2 in terms of chlorine residuals, turbidity levels, 3 bacteriological quality of the water, that kind of 4 information. 5 Q: And I also understand that they were also 6 the source of the information -- the settling information 7 that we'll discuss later in the report in terms of the solid 8 contact unit at the Surface Water Treatment Plant? 9 A: That's correct. 10 Q: And I understand Dr. Aramini toured not 11 only the Surface Water Treatment Plant, but the Groundwater 12 Treatment Plant and the -- the Sewage Water Treatment Plant? 13 A: I don't think he went to the Sewage 14 Treatment Plant, but he did go to the groundwater plants in 15 both North Battleford and Battleford. 16 Q: And I also understand you -- you did get 17 some assistance from SERM as well in terms of data? 18 A: Again, in terms of providing data to us, 19 they provided us with some turbidity data and also in helping 20 us in terms of the interpretation of some of the information. 21 Q: Okay, thank you. 22 A: So, just to give you a better sense of 23 the time line, it was the 25th of April that Dr. Eric Young 24 contacted the Director of the Field Epidemiology Training 25 Program to request assistance from the Federal Field

1 Epidemiologist in the investigation and that was when they 2 found Dr. Stirling down in Atlanta attending a conference and 3 quickly arranged for a flight to come up to North Battleford. 4 In addition, Dr. Young contacted myself, as 5 being part of the division that deals with waterborne 6 diseases, to make me aware of the situation, see what 7 expertise we would be able to lend. 8 The way that we've been working with the Field 9 Epidemiology Training Program is that, when the outbreak is 10 foodborne or waterborne in nature, that we get involved in 11 terms of helping to -- to supervise the field epidemiologists 12 in the field so that's been something that we've been doing 13 more and more recently. 14 Q: So, not only do you provide field staff, 15 you also provide supervision for the field staff, access to 16 your expertise of -- in -- of your division? 17 A: That's correct. 18 Q: Okay. 19 A: The field epidemiologists are -- are 20 stationed in various locations and with different programs 21 potentially within Health Canada or with -- with different 22 provinces so, for example, Dr. Stirling, who's normal job is 23 to work on tuberculosis, but he also gets involved in 24 outbreak investigations and this time it happened to be one 25 (1) that was waterborne so -- and that's how it works.

1 This was also, of course, the day that the 2 Precautionary Drinking Water Advisory was issued so that was 3 something that was already being put into place as we were 4 getting involved. This was something that they had already 5 been discussing and making decisions on before we had any -- 6 Q: Right. 7 A: -- real information as to the situation. 8 Q: So, just to clarify, Health Canada wasn't 9 involved in the decision to issue the Precautionary Drinking 10 Water Advisory that was issued on the 25th? 11 A: It -- they -- they were making the 12 decision, I can't remember the exact times of when that -- 13 the -- the Drinking Water Advisory was in place -- 14 Q: Maybe I wasn't clear -- 15 A: -- but they -- they -- 16 Q: -- they weren't asking you to -- to 17 advise us one (1) way or the other whether we go Advisory 18 or -- or Order -- 19 A: No. 20 Q: -- or whether we -- we don't do an 21 Advisory? 22 A: No. 23 Q: At that point it was just to get your 24 assistance to do the -- they've got a potential outbreak, 25 they want your assistance with the investigation?

1 A: That's right, that's right. 2 On the 26th of April was when Dr. Stirling 3 actually was able to arrive in North Battleford and, when he 4 arrived, what his job was to do was to get a better sense of 5 exactly what kind of studies had to be done, how certain were 6 we that it was even water at all. 7 We also weren't quite clear when he first 8 arrived as to whether it was the City of North Battleford or 9 the Town of Battleford that was the source of the 10 contamination, assuming it was water, so his job was to get a 11 better sense of the lay of the land, if you will, the kinds 12 of data that were available and to determine what kinds of 13 studies we needed to conduct. 14 Q: And -- and, at that point, even though 15 the advisory -- my understanding is a big part of the 16 investigation is still to determine source, even though there 17 has been an advisory, a decision hadn't been made that 18 it's -- it's waterborne, it -- we still need the 19 investigation to determine the source? 20 A: That's correct. 21 Q: That was the thinking at the time? 22 A: My understanding was that it was a 23 Precautionary Drinking Water Advisory -- 24 Q: Right. 25 A: -- on the 25th. And so people do that to

52
  1  be a prudent measure to protect the public but you want to
  2  put this in place.  But it's always a good idea to do further
  3  investigations, of course, to -- to confirm your hypothesis
  4  and to find evidence to support your hypothesis and that's
  5  what we set about to do.  
  6                 Q:   Yes.  And the concern is, if you go with
  7  an advisory and there's another source out there, that you --
  8  that you're really not doing much to control the outbreak?
  9                 A:   That's right.
 10                 Q:   Okay.
 11                 A:   That's right.  Dr. Aramini arrived on the
 12  29th of April and his function was going to be to look more
 13  at the water system.  That had been a lot of his role in the
 14  Walkerton investigation, was to look at the water quality
 15  data and he's done some research looking at water quality
 16  parameters.  So we had him taking more of a lead on that
 17  aspect.  
 18                 And as I mentioned, then Dr. Werker and I were
 19  back in -- she was in Ottawa, I was in Guelph and on the
 20  phone with -- with both of them constantly, it seemed.
 21                 Q:   Okay.  Go ahead.
 22                 A:   So just to give a better understanding,
 23  the overall purpose of our investigations, therefore, was to
 24  give us a better understanding of the scope of the outbreak,
 25  the magnitude of the outbreak and the likely source of the

1 outbreak and what contributed to that source becoming 2 contaminated. Those were our objectives. 3 Q: And just to back up a little bit -- 4 A: Hm-hmm. 5 Q: -- I understand that in terms of 6 supervising, that there was fairly regular, almost daily 7 telephone conference calls involving yourself, represen -- 8 Dr. Young, from SASK Health, Dr. Benade and other members of 9 the Battleford health district as well as your field staff 10 out here? 11 A: That's right. They were organized 12 conference calls or scheduled conference calls. I think we 13 started out twice a day, actually, and then -- but in between 14 that, we were -- we were on the phone, Dr. Aramini, Dr. 15 Stirling and Dr. Werker and myself, having other 16 conversations about the specific activities of our employees 17 on the ground. 18 So there was a lot of conversation going on. 19 Q: Right. And what I -- the point I want to 20 make is in those first number of days, it was very intense in 21 terms of -- of what was going on out in -- in Battleford -- 22 A: Yes. 23 Q: -- here. 24 A: Very intense. 25 Q: Both with your team, the SASK health

1 people and the Battleford health district people? 2 A: That's correct. 3 Q: Okay. 4 A: I'm sure most of you are all familiar, I 5 don't know if you can see that very well from the back, 6 here's just a map just showing us the Town of Battleford, the 7 City of North Battleford and the locations of both the -- the 8 well water, the groundwater treatment plant -- I think I have 9 a pen here. 10 Here, more to the north, then we have the 11 sewage treatment plant here further down and here's the 12 surface water treatment plant. So just in doing that 13 orientation which -- we've included that diagram in our 14 report. 15 Q: Okay. 16 A: In terms of the activities that were 17 undertaken afterwards, there were -- there were four (4) main 18 activities that are presented in the -- in the report. And 19 I'm going to be going through these each, a little bit 20 differently than how it's laid out in the document in terms 21 of the report. Because what I'm going to do is to go through 22 the -- the methods of each section followed by the results. 23 I think that will just be a little bit easier 24 to follow and rather than switching back and forth between 25 slides.

1 So first of all, there was a case series 2 analysis. And basically this is just trying to get us a 3 better idea in terms of the person, place and time parameters 4 we look at. So trying to get an idea of who was sick, when 5 they were sick, where all of these people located, that kind 6 of information. And that's -- I -- I'll go through exactly 7 how that data was collected. 8 As -- as for the surrogate to that we also 9 obtained information on anti diarrheal drug sales. We wanted 10 to get an idea of, was there -- is there other evidence that 11 we can gather that gives us an indicator that there was 12 gastroenteritis in this community happening and when did it 13 happen? When did it begin? 14 We also then go on to do what's called a 15 cross sectional study which is more of an analytic study that 16 helps us to determine what -- what were the risk factors for 17 becoming ill? And this is where we can actually come down 18 to, was it water or was it something else? Was it exposure 19 to a swimming pool? Was it exposure to some other factor and 20 we're always trying to keep an open mind when we go into 21 these things to make sure that we're covering off all of 22 the -- the most likely, potential sources. 23 Once we know that it's water, we can't stop 24 there, we also have to be looking at the -- the water quality 25 parameters so that we know, okay, yes, we believe it's --

1 it's municipal drinking water but which source is it? And in 2 the situation like Walkerton, for example, we had three (3) 3 different wells. And we had to try and figure out, well, 4 which well was it? 5 In this situation, you've got two (2) 6 different drinking water plants. What evidence do we have to 7 try and support that it was one (1) versus the other and what 8 kind of features of that -- that source were in place at the 9 time that could have potentially led to this kind of 10 contamination. 11 So, that's kind of our -- our thought process 12 that we're going to in, in designing these -- these kinds of 13 studies. 14 Q: Okay. One (1) question though, can you 15 tell me why it's important not just to do one (1) study, say 16 the cross-sectional study is -- what -- what is the 17 benefit -- it might be obvious, but what is the benefit to 18 doing all these types of studies, in terms of conducting this 19 type of investigation? 20 A: I think that any one (1) of these pieces 21 of information would not tell you enough. You really want to 22 have -- be looking at this problem from all kinds of angles. 23 You've got different questions being answered by the 24 different -- the different activities that we undertook. 25 And it helps to just build up more and more

1 supporting evidence to come -- to prove a certain hypothesis. 2 Q: And before you go on though. Dr. -- you 3 just spoke, Dr. Stirling arrived here on -- on April the 4 26th. I understand, and we've heard some evidence of this, 5 that there was a meeting that evening that information was 6 disclosed by SERM that might have changed the course of the 7 epidemiological, if I could use that properly. 8 I understand on the 26th is when people 9 learned that there was a problem, a particular problem with 10 the surface water treatment plant, and specifically the solid 11 contact unit? 12 A: Yeah, I believe that's the correct date 13 that we started to learn about the solids contact unit being 14 a potential -- a potential problem that could have -- that 15 could have led to this. 16 In some ways, you know, for us at that point, 17 that was you know, right away, early on in the investigation, 18 it wasn't something that changed our approach. It was 19 something that you file away and you think, okay, how are we 20 going to address this issue. 21 But we wouldn't want to make the assumption 22 just because we have that piece of information, that for sure 23 that was the cause. We really have to do these kinds of 24 activities to -- to substantiate that. 25 We would hate to think that it was the solids

1 contact unit only and not some other problem or, you know, 2 miss a water-main break, or -- or some other thing that might 3 have occurred. 4 Q: So -- 5 A: So -- 6 Q: -- this knowledge didn't limit the scope 7 of the investigation -- 8 A: No. 9 Q: -- whatsoever? 10 A: No. 11 Q: Okay. 12 A: It just gave us another thing that we had 13 to make sure that we were taking into account, or making sure 14 that we could develop some kind of approaches to -- to better 15 evaluate that event in time. 16 So, getting more specifically into the case 17 series study, as we call it. This is some more descriptive 18 analysis, trying to give us an idea of who the people are 19 that were being reported as -- as being ill. 20 So we're -- we're trying to get a better idea 21 from these people with gastrointestinal illness, in terms of 22 are they related to the outbreak, who was affected in terms 23 of their age and gender, the symptomotology of those 24 affected, was that symptomotology consistent with 25 cryptosporidiosis.

1 The time frame of the outbreak, the geographic 2 distribution of those who were affected. 3 And now we collected this information in a 4 number of different ways, and -- and we always have divided 5 it up into within the Battleford's Health Service area and 6 outside the Battleford's Health Service area. And this was 7 done upon request from the -- the province and the health 8 unit. 9 There's -- 10 Q: Does that -- does that have any 11 epidemiological significance that you split it within the 12 Battleford Health District Service area? 13 A: Not really, no, from -- from our point of 14 view it wouldn't have -- we could have looked at everybody 15 all together. But for -- for how they look at their 16 information it was of use to them to be divided in this 17 manner, so we did this. 18 But certainly those within the Battleford 19 Health Service area you would think would have more 20 opportunity to become ill than -- than the rest, but still 21 they would all be considered part of one (1) outbreak. 22 Q: Right, and -- and in any event, you were 23 doing geographic mapping anyway, that would show you where 24 the cases were -- 25 A: That's right.

1 Q: -- were appearing? 2 A: That's right. 3 Q: Okay. 4 A: So this -- this kind of information was 5 being gathered from a number of -- in a number of different 6 ways. 7 We developed what we call a line listing form, 8 and there is an appendix in your -- in the report, which 9 shows you the line listing form used in both of these 10 different areas. 11 Q: That's at -- Mr. Commissioner, the -- 12 those are appendixes -- appendices A and B, those are page 60 13 and 61 in tab 2, if you're following along. 14 A: So the first one (1), Appendix A, is for 15 within the Battleford's Health Service area, the other one 16 (1) is for outside the Health Service area. 17 And basically we're trying to populate 18 these -- these line listing forms. One (1) way was through 19 the emergency room chart review. Dr. Stirling spent many, 20 many hours at the Battleford's Union Hospital, going through 21 emergency room records to get a better idea of people coming 22 in for -- because they were presenting complaint of 23 gastroenteritis. 24 Getting an idea of age, gender, all those 25 kinds of parameters. Whatever he could get to give him an

1 idea of -- of -- to -- to fill out the standardized 2 information that we were collecting. 3 Q: And, on that, I understand that that 4 was -- that was taking place, you reviewed records from the 5 beginning of February all the way through until the end of 6 April as I understand from the report? 7 A: That's right, I think he even went right 8 back to the -- right into January. 9 Q: And -- and then, just so I understand, he 10 would take that information and -- and enter it into the -- 11 one (1) of these lines? 12 A: That's right, that's right, and he 13 wasn't -- 14 Q: -- charts. 15 A: -- because he wasn't collecting that 16 information first-hand, he wasn't always able to enter every 17 single field, for example. 18 However, this form was provided to the Health 19 Unit staff who were fielding phone calls from the public, in 20 addition to physicians in the area and long-term care 21 facilities and the emergency room after-the-fact. 22 Once we had the form developed, then the 23 emergency room had it to be able to -- to fill it in as 24 people came so that we were getting standardized information 25 on --

1 Q: So it's important to understand this is 2 all self-reported information, the contact is generally 3 initiated, other than ER chart review, the contact was 4 initiated by the patient? 5 A: That's right, people are -- 6 Q: With either the physician or the health 7 district? 8 A: That's right, people are -- are coming to 9 their physician, coming to the emergency room, coming to -- 10 or calling into the Health Unit to -- to report their 11 illness, that's how they -- the become -- you become aware of 12 them. 13 So there are certain pieces of information, 14 I'll -- I'll mention them when we get to them, that we always 15 have to recognize is based on people's recall of what they 16 believe or what -- the date that they believe they got sick, 17 that kind of thing. So, there's always going to be a little 18 bit of inaccuracy in that information. 19 Q: And I understand that you refer to that 20 in -- as recall bias; is that -- 21 A: That's correct. 22 Q: -- so -- in -- as we go along, if you -- 23 you say recall bias, we'll know what you mean, it's -- 24 A: Yes. 25 Q: -- it's the -- everybody's memory isn't

1 perfect is -- 2 A: That's right, that's right. 3 A similar kind of form was also developed for 4 people outside of the Battlefords Health District and a 5 similar kinds of information was collected, for example, the 6 kinds of things we were looking at, again, were demographics, 7 their location of residence, the symptoms that they 8 experienced, the type of medical attention that they sought, 9 whether a stool specimen had been submitted or not and if 10 they knew the result of that specimen and if they had drank 11 North Battleford water prior to their illness. 12 Then we also -- for the people outside the 13 Battlefords Health service area, wanted to know exactly when 14 they were in the Battlefords and what kind of activity they 15 took part in, if it was a specific event because, of course, 16 we're always worried if there was a particular community 17 event that could explain all of these cases, and exactly 18 where they were within the region. This -- this collection 19 of data continued until the end of May. 20 And another thing I wanted to point out is 21 just that, because there were multiple sources of information 22 that -- information was being collected through multiple 23 sources, that we did go to extensive trouble to make sure 24 that we omitted any duplicates so that was done either by the 25 health unit or by the province, depending on which dataset we

1 were looking at to make sure that people who visited their 2 physicians, for example, hadn't also been calling into the 3 health unit. So, that we had two -- two (2) records on the 4 same person, we made sure those were removed. 5 Q: Okay. 6 A: Now, once we've -- we've been collecting 7 all this information on these people who are calling in who 8 we suspect are related to the outbreak, we have to, as a 9 standard thing that we do in all epidemiological 10 investigations, is we have to come up with what we call a 11 case definition. 12 And this basically helps to set out some 13 criteria that are standardized that we will use when we are 14 considering whether or not a person is, in fact, related to 15 the case. We -- or, sorry, to the outbreak. 16 We don't want to only be using people who, for 17 example, went to the emergency room because those people are 18 obviously among those who are the most ill or only people who 19 were confirmed with cryptosporidium parvum in their stool 20 sample. Because, again, we know that most people never go to 21 the doctor with these things and never -- or might even not 22 get tested if they do go the doctor we -- we used the 23 symptomotology and other criteria to try and give us a 24 definition of what we consider to be an epidemiologically 25 linked case, even if they aren't, in fact, laboratory

1 confirmed. 2 So our first definition is, for the 3 epidemiologically linked cases, and so this included anybody 4 who was a resident of the Battlefords or a visitor to the 5 Battlefords area who had an onset of diarrhea after March 6 20th. 7 Now, that date is there because this -- this 8 definition was refined after we had gotten more and more into 9 our analysis and we're beginning to believe, yes, we do think 10 that that March 20th event with the solids contact unit was 11 significant, we had that date. 12 Prior to that, we were really looking into 13 February for -- for even this -- this study. 14 Q: Before -- just before you go on there, 15 it's important to understand we're -- we're developing a case 16 definition. But that does not mean you throw out data from 17 people who don't meet the case definition. All that data is 18 used by -- 19 A: That's right. Those people are still 20 included in the data -- I'll show you some graphs later where 21 we've included those people on the graph, but they are in 22 fact included cases. And the -- the benefit of having that 23 information on those people is it gives you an idea of where, 24 sort of the base line was before the outbreak began. 25 So that -- those people are -- are -- as

1 useful to us as -- as those who we did consider to be a case. 2 Q: Right. The case definition isn't 3 exclusionary, it's a way of differentiating people -- 4 A: That's right. 5 Q: -- who have reported? 6 A: That's right. The other thing is, we say 7 after March 20th as opposed to on March 20th, that's 'cause 8 the minimum incubation period for cryptosporidium is believed 9 to be one (1) day. So they would have had to have an onset 10 date of the 21st or after, so -- of March. 11 Q: And -- and just to understand it, epi- 12 linked. You're not linking it to a source, this is to -- 13 we're talking about an outbreak of gastro enteric disease, 14 isn't that what -- what -- ? 15 A: That's right. They -- they're part of 16 the outbreak we believe and so they might have gotten it 17 directly from the water or they might have been a secondary 18 case who received it person to person transmission within a 19 household where there are others who became ill from the 20 water. They -- they're linked to the outbreak. 21 Q: And -- and this is -- and just on that 22 point, this is -- this study, we need to be clear, isn't the 23 one (1) where we get to assessing risk factors? 24 A: That's right. 25 Q: And tying it to a particular source.

1 This is a descriptive study to give us an idea of maybe how 2 many people get -- are getting ill, when they're getting ill 3 and -- and where they're getting ill? 4 A: Exactly. 5 Q: Okay. 6 A: Exactly. A confirmed case, again, 7 another definition is just simply they met the criteria for 8 the above definition for an epidemiologically linked case but 9 they also had a stool specimen that was positive for 10 cryptosporidium parvum oocysts. 11 Okay. So in total, for all of these -- for 12 both within the Battlefords and outside of the Battlefords, 13 from the entire case series, they're actually nineteen 14 hundred and seven (1,907) people who are identified who met 15 the case definition. And I'm going to go through, again, 16 within the Battlefords and outside the Battlefords service 17 area, presenting that information. 18 Q: And -- and before you do that, I hate 19 to -- 20 A: Yes? 21 Q: -- interject again, but I just wanted 22 to -- to talk a little bit about why diarrhea as a symptom -- 23 A: Oh. 24 Q: -- as -- as one (1) of the gastro enteric 25 symptoms was preferred over say stomach cramps or one (1) of

1 the other symptoms that are seen from time to time? 2 A: That's right. The one (1) of the 3 hallmark or cardinal signs cryptosporidiosis is the person 4 will have diarrhea or they should have diarrhea. Certainly 5 you might have a really mild case that didn't have diarrhea, 6 had very severe cramps but that would be unusual. 7 So we want to go with what's the norm. We 8 don't want it to be too stringent. For example, in the 9 Milwaukee outbreak in 1993, if you read their paper, they 10 used the criteria of, it had to be described as watery 11 diarrhea. But they go on in their discussion to say that 12 they felt maybe that was being a little bit too -- too strict 13 in their criteria, that just diarrhea would have been -- 14 would have been a better description. 15 Ideally we like to classify diarrhea by -- or 16 consider something to be diarrhea by quantifying the number 17 of loose stools in a twenty-four (24) hour period. 18 Because -- that wasn't asked in a standardized way in the 19 case series at the beginning. So later on I'll show you in 20 our -- in our cross sectional study where we made sure that 21 they met that criteria. 22 But we wanted to make sure that just people 23 who were calling in saying, oh, I had a touch of a fever and 24 a little bit of stomach cramps, they weren't included as a 25 case, even though they were in the Battlefords area.

1 We just had to have something to kind of 2 standardize who we were including, because obviously there's 3 always going to be some people having some kind of gastro 4 intestinal upset during any time period. 5 Q: Right. And you just -- you don't want to 6 capture everyone that has tummy ache. So to some extent, 7 developing these -- these case definitions, is a judgement 8 call based on the type -- the nature of the pathogen you're 9 dealing with? 10 A: That's right. 11 Q: So in this case, diarrhea was picked 12 because it's almost always present with there's a -- a case 13 of cryptosporidiosis? 14 A: Yes. 15 Q: Okay. 16 A: Yeah. So looking at the people within 17 the Battlefords health service area, people were identified 18 on these line listing forms that I've been talking about. 19 There were thirteen hundred and seventy-six (1,376) people 20 for whom information was gathered. And when we looked at the 21 criteria for meeting the case definition, just overall 22 whether they're epidemiologically linked or confirmed, the 23 total was one thousand and thirty-nine (1,039) people. 24 Of those, a hundred and ten (110) were 25 laboratory confirmed with cryptosporidiosis. So the balance

1 were only epidemiologically linked. We then take those 2 people and we plot them out on a curve such as this where we 3 have the date of symptom onset. So this is when they're 4 symptoms first began, we have that along the X axis. 5 And then we have the number of individuals 6 with those -- who meet these different criteria, along the Y 7 axis. 8 And what you have here is that confirmed cases 9 are in red, the epidemiologically think cases are in yellow, 10 and those who -- because they were before the 20th of March, 11 we felt were not related to the outbreak, but they did report 12 diarrheal illness. 13 And as you can see, what we've -- what 14 we've -- what we've gleaned from this is that we have that 15 March 20th date highlighted there with the arrow, that after 16 that we see a dramatic increase in -- in people beginning to 17 have symptoms of gastroenteritis in -- within the 18 Battleford's Health Service area. 19 Again, because these are the dates that people 20 are recalling that they -- their symptoms began, there can be 21 some inaccuracy there, so we don't want to look at a specific 22 person and point and say, well for sure that person's 23 diarrhea began on March the 30th. That kind of accuracy we 24 can't count on. 25 But certainly the general trend is what we're

1 looking at, and what we see is that there is a very dramatic 2 rise in gastroenteritis after that time. 3 Q: With the numbers of people that reported, 4 and we have -- and -- and with this particular -- with the 5 people inside the service area, there's thirteen hundred and 6 seventy-six (1376). 7 Would you expect, even considering recall 8 bias, much of a shift in the curve you're showing us there? 9 A: Well certainly some people -- it's very 10 hard to make that judgment. Certainly some people will be 11 inaccurate in what they've judged. 12 Also people might have had some other kind of 13 diarrheal illness that occurred earlier on in January or 14 February that was because of something else, and before they 15 ever got better they were -- they were infected with 16 cryptosporidium, and so now they've got something else. 17 But when you ask them, when did your symptoms 18 start, they might say, oh, way back in February. But in fact 19 the current thing that we're talking about, really they 20 didn't -- it didn't occur until later on, but it just was all 21 sort of washed together in their memory, so it's harder for 22 them to determine the exact date. 23 So there's always going to be that bit of 24 inaccuracy, because these are recall dates. I do want to 25 make it clear too, that these are dates of onset of symptoms.

1 So people are -- are going back in time. It's not like these 2 people would have been obvious to any laboratory or anything 3 else on those particular dates, because those are their 4 symptom onsets. 5 So for example there's -- there's always a lag 6 time in terms of people coming to the attention of the health 7 care system, in terms of lab confirmation, for example, 8 because you'll be ill with diarrhea and cryptosporidiosis is 9 a fairly mild gastroenteritis typically, so people will not 10 necessarily go to their doctor for a matter of days, maybe a 11 week. And then they might get a stool specimen taken, maybe 12 not, maybe they'll be on their second visit. 13 So we -- we can count on a couple of weeks at 14 least delay in people actually getting somehow reported 15 through the normal reporting system. So just to keep that in 16 mind when you're looking at these dates. 17 Q: Yeah, and what you're saying there is, 18 just to be fair, the recall -- Dr. -- we know Dr. Stirling 19 came out on the 26th, and the information is starting to get 20 gathered in these days, so some people are looking, like you 21 say, back one (1) or two (2) weeks trying to remember -- 22 A: Yes. 23 Q: -- when -- when they -- the first day 24 they -- they noticed the symptoms. 25 A: That's right, and again it's just the

1 emphasis thing that it's the trend that is important here. 2 That it seems to be after that date that we see this rise. 3 Q: And one (1) thing you did mention to us 4 in terms of picking the case definition was the minimum 5 incubation for cryptosporidium, that appears in the 6 literature I understand. Can you tell me what the average 7 incubation period is? 8 A: Yeah. The average incubation period is 9 supposed to be about seven (7) days. So if we think going 10 forward from the 20th seven (7) days, you're talking about 11 the beginning of April. 12 What we see here is that the peak of the cases 13 seems to be about the 13th of April. And then we almost have 14 another peak, if we can consider this to be the first peak we 15 also have another peak approximately seven (7) days later, 16 which we can consider to be almost secondary transmission to 17 be part of that, because those people who became ill at 18 first, could have now become ill from exposure to their 19 family members who were ill with diarrhea and so they would 20 get sick a little bit later on. 21 Q: And -- and that points out, that's 22 another limitation with the case series study, for example, 23 it won't differentiate between a primary case and you call a 24 secondary case? 25 A: Yeah, it's always very difficult with a

1 waterborne outbreak, because everybody's exposed to water. 2 Q: Right. 3 A: Pretty much. So it's very difficult 4 to -- to determine who -- you know, did they really get sick 5 from the person with diarrhea, or was it their own 6 consumption of water that -- that was the problem. 7 So it can be very tricky to determine that. 8 We do later on, in our cross-sectional study, get into that, 9 because we have to look at the secondary cases and actually 10 not include them in our analysis. So, I'll explain that in 11 more detail when we get there. 12 Just to give you an idea of the age 13 distribution of those who were affected within the 14 Battlefords Service area, what we found was that the -- the 15 age range, from anywhere from less than a year to greater 16 than ninety (90) years of age, the majority were either 17 between one (1) and nine (9) years of age or twenty (20) to 18 forty (40) years of age, 55 percent were female and 45 19 percent were male. 20 Just to give you a little bit of an idea of 21 some of the other symptoms that people were reporting, of 22 course, 100 percent had diarrhea because that was our case 23 definition, but, in addition, abdominal pain or cramps 33 24 percent, vomiting 29 percent, you can see the percentages 25 here, nausea, malaise, anorexia, fatigue, fever, weight loss

1 were some of the other symptoms that were reported and all of 2 these would be consistent with what we would expect to find 3 with this particular infection. 4 Now, in addition, just going back, I just 5 wanted to point out that there were also three hundred and 6 eighteen (318) people who visited a physician, that was 31 7 percent of people reported visiting a physician, two hundred 8 and fifty-six (256) people went to the emergency room and 9 there were twenty-eight (28) people hospitalized. 10 This is a map that gives you an idea of where 11 people were located within the Battlefords health service 12 area and, again, I apologize to those in the back who can't 13 see this as well. 14 You can see these -- the -- the dots represent 15 the numbers of reported cases in varying intervals which are 16 defined here and, as you can see, the largest dots are down 17 here around the City of North Battleford and the Town of 18 Battleford with six hundred and thirty-nine (639) people in 19 North Battleford, one hundred and thirty-six (136) in the 20 Town of Battleford. 21 Just to let you know, we did have people sort 22 of sprinkled all over the health service area in low numbers 23 in some cases that just would reflect into their visiting the 24 area. 25 Q: And, just for counsel, that's at page 26

1 if they can't see the slide of -- of tab 2. 2 A: Now, moving onto those from outside of 3 the Battlefords health service area. Again, we obtained 4 information from a total of nine hundred and fifty-five (955) 5 people, both from -- anywhere outside the health service area 6 so this included other provinces, as well as within the 7 Province of Saskatchewan and, of those, eight hundred and 8 sixty-eight (868) met the criteria for being a case, a 9 hundred and fifty-five (155) of them were, in fact, 10 laboratory confirmed. 11 Q: And on the cases from outside, I'm 12 looking at Appendix 'B' at page 61 again. Can you tell me, 13 as I look, it's about the sixth column over, what's the 14 significance of picking twenty-one (21) days as the -- the 15 date -- 16 A: We wanted to know if they travelled to 17 the Battlefords Service area in -- in the twenty-one (21) 18 days prior to their illness and that's considered to be kind 19 of the maximum incubation period for cryptosporidiosis. 20 Some place an alert trip might even be a 21 little bit more than that so we -- we picked that time frame 22 just to see whether or not they were, in fact, in the area 23 during the time relevant before their -- their illness. 24 Q: Okay. 25 A: Again, when we go ahead and plot these on

1 a curve in a similar format to what I described previously, 2 you see that the peak of the cases is, in fact, quite a bit 3 later, it's more around the 23rd of April among these people 4 and that turns out to be about a week or so after the Easter 5 weekend so conceivably a lot of people came to this area 6 during that time frame. 7 We understand that there were a lot of 8 different community events taking place during that time and 9 that would potentially be an explanation. We don't know that 10 for sure, but it still follows a similar kind of increase. 11 In terms of the visit dates for -- for when 12 people came and -- and where they visited, the visits 13 location was, in fact, only available for six hundred and 14 ninety (690) of those eight hundred and sixty-eight (868) 15 cases -- sixty-eight (68), is that correct? Sorry, yeah, 16 sixty-eight (68) cases. 17 Of those, 86 percent visited the City of North 18 Battleford, 8 percent the Town of Battleford and 6 percent 19 visited both. Some of the reasons for being -- for visiting, 20 those were only available for about a quarter of the people 21 who reported -- were considered to be cases, half of them 22 went to some kind of a dance event that occurred in -- in the 23 Battlefords area, 5 percent went to a casino event and 14 24 percent were at a church camp. 25 I want to just point that, among the reasons

1 for -- for their visit, there could be some bias in terms of 2 over-representation from certain groups because certainly, 3 if -- if a number of people, for example, in the dance 4 troupes were ill, then they would all have continued contact 5 with each other which could lead to one (1) -- one (1) of two 6 (2) things. One (1) would be communication to, hey, let's 7 make sure that we report everybody. The other thing would 8 be, increased opportunities for secondary transmission within 9 those groups. 10 Q: Right. 11 A: So that could -- that could lead to over 12 representation within certain groups. 13 Q: So, for example, a group of young dan -- 14 a dance troupe from Saskatoon are together as opposed to a 15 bunch of people showing up at a casino event that may not see 16 each other again? 17 A: That's right. They continue -- 18 Q: -- 19 A: -- to be together. And I know that 20 some -- some people who came for certain events took it upon 21 themselves to make sure that they surveyed everybody in their 22 group to find out who was ill, who was not ill and provided 23 that kind of information. 24 Q: So we don't -- we don't draw a lot from 25 that information? It's just --

1 A: No. 2 Q: -- there, okay. 3 A: It just gives you an idea of what people 4 were doing. 5 Q: Okay. 6 A: In terms of the visit dates recorded, 7 those were available for five hundred and seventy-eight (578) 8 people. The majority we found visited between the 12th of 9 April and the 26th of April. So that helps to also explain 10 why that's within the curve, it's going to be later on, as 11 most of them came around the 12th. 12 And among those that visited for only one (1) 13 day or less, their visit dates ranged between March 23rd and 14 May the 6th. So there was nobody who came for just one (1) 15 day to the Battlefords, who was here prior to March 20th, who 16 became sick. Anybody who was here only for one (1) day, it 17 was after March 20th, who became ill. 18 MR. COMMISSIONER: All right. Is this a good 19 point to take the morning break, or -- ? 20 MR. CHRISTOPHER BOYCHUK: Well I can -- we 21 only have a few more slides and then we'll get to a whole 22 other case. It might be five (5) more minutes will take us 23 to the next investigation technique, Mr. Commissioner, if 24 that's okay. 25 MR. COMMISSIONER: Very well.

1 MR. CHRISTOPHER BOYCHUK: And that will be a 2 logical place to break, I think. 3 THE WITNESS: Okay. This just shows us the 4 age distribution for those people living outside of the 5 Battleford service area. And you can see that this is a 6 little bit different from what we saw for those within the 7 service area. Here, the majority of people were between 8 thirty (30) and forty-nine (49) years of age. And the 9 children tended to be older children which could again 10 reflect children who would be coming for those kinds of 11 different activities, they're be more of the age where they 12 would be taking part in those activities and visiting another 13 area. 14 MR. CHRISTOPHER BOYCHUK: Okay. 15 THE WITNESS: When we look at a map, again, 16 you might want to give the page reference for that, people 17 who were outside of the Battlefords health service area, 18 we've blacked out the -- the Battlefords health service area 19 on the left side and the rest of them, with the darker tones, 20 are the ones that had the most cases. 21 So you can see that the majority of them are, 22 in fact, in close proximity to the Battlefords health service 23 area, or they're those areas that had higher populations, as 24 we would expect. So there's more opportunities for people to 25 come and be taking part in activities here.

1 In addition, it was interesting to note that 2 there were other provinces that reported illness. A hundred 3 and forty-one (141) people from Alberta said that they had 4 been to this area and became ill. I believe there was a big 5 group among those people that all came together. Manitoba, 6 there were nineteen (19) and British Columbia, seven (7). 7 Another shift that was done, now this was more 8 by the -- by the laboratory side, but I think it's important 9 to -- to make note of this, is that, as part of this, we 10 always want to make sure that there's been laboratory 11 investigations done for other pathogens. 12 When people submit a stool sample, especially 13 at the beginning, before the outbreak's been identified, 14 these stool specimens are screened for, first off is 15 bacteria, that's normally what they're first screened for. 16 And had there been an increase in bacterial infections, we 17 would have had increased notifications to the health 18 department that there were, in fact, increases in different 19 bacteria. 20 CONTINUED BY MR. CHRISTOPHER BOYCHUK: 21 Q: Just on that, that's provided, of 22 courses, it's notifiable type of condition? 23 A: Provided it's a notifiable -- but if 24 people are sick and are having stool specimens taken, chances 25 are it's going to be something that's notifiable.

1 Q: Okay. 2 A: There are also no other kinds of 3 parasites other than cryptosporodium parvum in the stool 4 specimens that were being submitted. 5 Q: I just want to back up. I -- I 6 understand that the provincial lab and the other labs 7 automatically when they do a parasite examine, check for -- 8 your understanding is they check for giardia as well as 9 crypto? 10 A: That's right. 11 Q: Okay. 12 A: There also were no viruses detected. We 13 actually had -- Dr. Horseman did take twelve (12) randomly 14 selected stool specimens, tested them for viruses. No 15 viruses were detected among them. 16 Just because, we want to make sure that we're 17 not missing out on other things that could be causing 18 gastroenteritus in the community, other than cryptosporodium 19 parvum. 20 In addition, just to add further evidence 21 that -- that we believed that we were only dealing with 22 cryptosporidium parvum is that other laboratories in 23 Saskatchewan, Manitoba, Alberta, British Colombia, when they 24 were testing people who were sick with diarrhea, who visited 25 the North Battleford area, they only were detecting

1 cryptosporidium parvum in those stools. It wasn't like there 2 were other things involved. So, this helps us to feel more 3 confident that this was indeed an outbreak 4 ofcryptosporidiosis. 5 So finally, the final slide for this case 6 series is -- is our overall interpretation. We -- we 7 recognize that the people who were affected were across all 8 age groups and both genders. 9 So it wasn't that this was something that was 10 isolated to one (1) segment of the community, which lends 11 evidence to suggest that this is something that's 12 ubiquitously consumed. Or there's a -- a very widespread 13 exposure. 14 Most of the people who were ill were either 15 residents of the Battlefords, but there were also many 16 visitors who were affected, and including people who just 17 were here for only one (1) day. 18 And also the majority of the people became ill 19 in mid to late April, although it seemed to have begun around 20 the end of March, and that cryptosporidium parvum, as I said, 21 was the causative agent. 22 So that's the kind of information that we 23 glean from these kind of case series studies. It all 24 suggests that -- that we are dealing with something that was 25 most likely waterborne, because we -- we have a broad cross-

1 section of the population affected. 2 One (1) particular location seemed to be a 3 common place that others who were in the province or other 4 parts of the health service area had visited, or had some 5 kind of contact with. So it helps to add evidence that there 6 was something going on in that location, and there was no 7 kind of a community event or anything else that could have 8 accounted for -- for all those people becoming ill. 9 Q: But based on this information, you 10 aren't -- you aren't excluding other sources based on this 11 information yet? 12 A: No, I think what this information can 13 primarily tell us is that during this time frame there were 14 numerous people who either lived here or visited here, who 15 became ill with gastroenteritis. And cryptosporidium parvum 16 was the causative agent, so what they became ill with. 17 And -- and that tells us -- that's basically 18 what it tells us, it's very suggestive that it's water, but 19 we go on to do other studies to help to -- to further 20 substantiate that. 21 Q: That takes us to the end of this study, 22 so this would be a good time I think if you're -- you want to 23 break. 24 MR. COMMISSIONER: All right, we'll take a 25 fifteen (15) minute morning break then.

1 --- Upon recessing at 11:03 a.m. 2 --- Upon resuming at 11:24 a.m. 3 4 MR. COMMISSIONER: All right, perhaps we'll 5 resume if you would take your seats please. 6 7 (BRIEF PAUSE) 8 9 CONTINUED BY MR. CHRISTOPHER BOYCHUK: 10 Q: Dr. Ellis, when we last left off we were 11 dealing with -- 12 MR. COMMISSIONER: Oh sorry, before you 13 start, Mr. Boychuk, I gather for the record, we kind of 14 assumed that Dr. Ellis was a -- an expert in the epidemiology 15 and to the extent it's reasonable to find in the absence of 16 any objections, I'll qualify her as an expert in epidemiology 17 for the record. 18 MR. CHRISTOPHER BOYCHUK: Thank you. 19 MR. COMMISSIONER: Thank you. 20 21 CONTINUED BY MR. CHRISTOPHER BOYCHUK: 22 Q: We had left off before the break with the 23 case study. One (1) of the other investigation techniques 24 that you told us about was the anti-diarrheal drug sales 25 review.

1 So could you tell us about that? 2 A: Sure. Basically one (1) of the -- the 3 purpose of looking at anti-diarrheal drug sales was to get a 4 little bit more information, or evidence to illustrate the 5 fact that there was an increase in gastroenteritis in the 6 community, and get a better sense of the time frame during 7 which this was occurring. 8 I just want to make clear before I go into 9 this, that anti-diarrheal drug sales are certainly not 10 anything that we in public health have available to us in 11 real time on an ongoing basis. 12 I'll show you -- what I'm going to show you 13 will show us how useful this information is, but it's not 14 something that comes to us normally through the normal 15 processes, but certainly is another way of getting a feel of 16 whether or not there's an increase in gastroenteritis in the 17 community. 18 Q: So in -- in a lot of ways it's a -- it's 19 a -- you're looking for the same type of information that you 20 sought with the case study? 21 A: That's right. 22 Q: Is that right? 23 A: That's right. 24 Q: Okay. 25 A: And so the way that we went about doing

1 this was, the -- the pharmacies that were selected, first of 2 all, were all in North Battleford and it was basically a 3 convenient sample of pharmacies, first of all, that were 4 willing to participate and they also were chosen by their 5 size and their likelihood of having computerized records and 6 a retrievable database on their -- their unit sales for a 7 variety of different anti-diarrheal drugs. And we certainly 8 greatly appreciated the cooperation of those pharmacies that 9 took -- took part. 10 We asked them for unit sales information so -- 11 and -- and how they provided us this information varied 12 actually between the three (3) different pharmacies that we 13 were able to obtain information from. 14 So they used three (3) slightly different sets 15 of drugs and had slightly different reporting periods for 16 their unit sales, but we -- we were just happy to get 17 whatever information we could and so we had to analyse them 18 all independently. 19 In addition, we asked them for information not 20 only for January to May of 2001, which was the period of 21 interest, but we also asked them for 2000 data for that same 22 time frame so that we'd have a comparison to see how things 23 looked last versus this year. 24 Q: And -- and on that point, you were 25 talking -- these are over-the-counter medications, these

1 aren't prescription drugs that you are -- 2 A: That's right. 3 Q: -- monitoring? 4 A: These are over-the-counter drugs that 5 people could go and -- and purchase for themselves, if they 6 were going down south on a trip that they were worried that 7 they might get gastroenteritis while they were on vacation, 8 they might go and -- and purchase some of these medications 9 so things like Pepto Bismol, Kaopectate, Lomotil, those kinds 10 of things. 11 Q: And what would be the -- the rationale 12 for selecting over-the-counter as opposed to prescription 13 drugs? 14 A: Well, what we're trying to do is to get a 15 better sense of -- of people before they've even accessed the 16 medical -- the physician care system so these people are 17 people who have been home with diarrhea, they've decided I'm 18 going to take something to try and get rid of this since it's 19 persisting longer than I would like and they go to the 20 drugstore and treat themselves. 21 They probably haven't necessarily sought 22 medical attention when they've gone to purchase these -- 23 these medications. So it brings us a little bit closer to 24 what's happening in the community, as opposed to just relying 25 on those that then get reported to us by physicians or by

1 laboratories. 2 Q: And another reason, I understand, is that 3 with something like cryptosporidiosis, which can often be a 4 mild infection, there's -- there's data that suggest that the 5 number of people that actually seek medical attention is -- 6 is fairly low, relative to the number of people -- 7 A: That's right. 8 Q: -- who get ill; is that correct? 9 A: A lot of people won't -- a lot of people 10 won't go to the doctor, it is something that's a mild 11 illness, it can persist for a number of weeks so, unlike your 12 usual viral gastroenteritis, which will -- you'll be better 13 anyhow in a couple of days, unless it's -- there's some sort 14 of other complicating factors, this is something that can 15 persist for a little bit longer so probably these anti- 16 diarrheal drug sales and these -- with this particular 17 organism is quite a useful thing to look at to get an idea 18 of -- of gastroenteritis in the community. 19 Q: And -- and on the issue of people going 20 to the physician, I understand that your own -- the studies 21 that we have -- that you have carried out here showed were -- 22 were down in the low teens in terms of the numbers that 23 actually seek medical attention -- 24 A: Yeah, it's a little bit higher -- 25 Q: -- compared to the numbers that reported;

1 is that right? 2 A: Yes. Just going back to my notes here 3 regarding the numbers that went to the physician, for 4 example, within the -- within the Battlefords area, 30 -- 5 actually, no, it was more like 31 percent visited physician, 6 25 percent went to the -- 7 Q: Sorry. 8 A: -- emergency room, 3 percent 9 hospitalized. So a lot of people did, but often, again, 10 that's going to be later on in the course of their illness. 11 This also helps us, again, with the time frame 12 because that might be the -- one (1) of the -- the first 13 measures that they'll take before they go to the doctor. 14 Q: So, bottom line, what you're doing is, 15 by -- by picking over-the-counter, is to capture a larger 16 sample of people that are showing gastroenteric -- 17 A: That's right. 18 Q: -- symptoms? 19 A: That's right. 20 So, here we have the results from what we 21 called Pharmacy 'A' for January to May 2001. On the bottom 22 you'll see their sales week, which I believe were recorded as 23 calendar weeks for this pharmacy. 24 And you can see their -- their numbers of unit 25 sales on the -- on the 'Y' axis. Again, the date of the

1 Surface Water Treatment Plant maintenance is -- is there, as 2 well as the Precautionary Drinking Water Advisory. 3 And what we find, if we average out the -- the 4 mean unit sales prior to the 18th of March, they sold about 5 fourteen (14) units per week during that time frame, but by 6 the week of April 8th, their sales jumped more than five (5) 7 fold to seventy-six (76) units. 8 When we look at what we called pharmacy B. 9 Here we were able to obtain information on -- for the year 10 2000 and 2001. And you can see that, in the year 2000, which 11 are the white bars, things are kind of going along at a 12 fairly steady -- steady rate. There's no dramatic increases, 13 sometimes there's a little bit more than others. 14 As I mentioned, we do expect to see a little 15 bit of an increase in sales at times when people are going 16 down to some countries where you might go in the winter time 17 to seek some winter relief, but, might be concerned about 18 developing gastroenteritis. 19 However, in 2001, we certainly see, again, a 20 dramatic rise during that period in early April. And so for 21 this pharmacy, what we were looking at was a mean of twenty- 22 five (25) units per week that had actually doubled by the 23 week of March 29th to April 4th. And then by the week of 24 April 12th to 18th, we had actually a maximum of a hundred 25 and thirty-one (131) units sold.

1 Finally, what we called pharmacy C, here the 2 information was only able to be presented to us in four (4) 3 week sales periods. So we have them clumped into four (4) 4 weeks. But we did have both years. 5 Again, 2000 we see a fairly consistent pattern 6 in sales but in the year 2001 the -- the numbers of units 7 sold jumped from eighty-five (85) units for the four (4) week 8 period prior to March 24th, as an average. And then to a 9 total of four hundred (400) units -- four hundred and twenty- 10 six (426) units, actually, between March 25th and April 21st. 11 So the nice thing about this information is 12 that -- just moving to my overall interpretations, it 13 provides evidence to further suggest that there was an 14 increase in gastroenteritis in North Battleford beginning at 15 least by the first week of April. 16 It also helps to show us the usefulness of 17 this kind of information because this -- this information 18 is -- is very objective, there's not going to be any kind of 19 reporting bias or recall bias or anything like that. It -- 20 it's computerized sales data. It's collected for a different 21 purpose. 22 So the fact that there was tons of media here 23 and -- and the Boil Water Advisory in place, wouldn't 24 necessarily prompt people to go and buy any diarrheal's, they 25 would do it because they were ill. And I don't believe there

1 was ever a report put out to, you know, go and get your -- 2 your Kaopectate or anything else, if you actually were 3 feeling sick. 4 Q: Right. And as we look at the charts, 5 the -- the majority of the sales are before the precautionary 6 drinking water is advised -- or advisory is issued. 7 A: That's correct. 8 Q: So in a sense that -- people wouldn't 9 have known of a problem with water that would maybe encourage 10 them to go buy -- buy these products. 11 A: That's right. It really -- if we go back 12 a couple of slides, you're right. It's before that was even 13 issued, people weren't aware that there was this concern. 14 And yet they're going and seeing this kind of medication. 15 So it gives us a good surrogate measure of 16 the -- of the gastroenteritis. And this really helps to 17 illustrate our problems with surveillance for gastroenteritis 18 in the community because there can be a lot going on before 19 anything will ever kick in to actually notify us that there's 20 a problem. 21 Until we start seeing people showing up in 22 emergency rooms, at physicians or being laboratory confirmed, 23 we're not going to be hearing about it. 24 Q: And is that particularly with a -- with 25 a -- a pathogen like cryptosporidiosis which might have a

1 long incubation period, relatively speaking? 2 A: It would be a little bit worse with 3 cryptosporidium then, for example, with something like E.coli 4 0157:H7 that we saw in Walkerton where people become ill 5 within about three (3) days, get very severe, bloody 6 diarrhea, really badly affecting children and the elderly. 7 Much more serious, more severe illness. 8 Q: Right. And typically because the 9 symptoms in cryptosporidiosis aren't that severe, again, that 10 that -- that feeds the problem that you spoke of. 11 A: That's right. It just makes it worse. 12 Q: And before you go on, the one (1) thing 13 that is -- is consistent is that all the peaks for the sale 14 of anti diarrheal -- anti diarrheal medications were before, 15 in each pharmacy, before the Precautionary Drinking Water 16 Advisory was issued? 17 A: That's right. And even reports after the 18 20th of March. 19 Q: Okay. 20 A: Okay, so to move into the third part of 21 our study. This was a cross sectional study and -- and here 22 is where we actually did a survey of the community. And this 23 had two (2) purposes. One (1) was to obtain information 24 regarding risk factors for illness. The other one (1) was to 25 allow us to make some community based estimates of illness,

1 to give us an idea of what was really the magnitude of this 2 outbreak? How many people really became ill with diarrhea 3 during this time frame? 4 And the way that we set about doing this, is 5 we -- we come up with a random sample of households, and the 6 number of households that we're going to sample is derived 7 by -- we actually put numbers into a software package to 8 calculate sample size, and that takes into account the size 9 of the community that we're serving, the likelihood of their 10 exposure, the likelihood of them developing illness if they 11 are exposed. A number of different parameters that we have 12 to take from the literature. 13 Q: And can you tell us what -- what the 14 sample size you are aiming for here? 15 A: So in this case, yes, we were looking for 16 a sample size of about two hundred and fifty (250) 17 households. 18 Q: And you felt that would be necessary to 19 give legitimacy to your study? 20 A: That's right, it's all about statistical 21 power and being able to make the calculations and have -- be 22 able to show something that is actually statistically 23 significant. 24 And so for that reason we had to make sure 25 that we had at least two hundred and fifty (250) households

1 in our survey. 2 Q: And you've -- you've got -- it's a random 3 survey, that's important to the -- to the study methodology 4 as well? 5 A: That's right, when making it a random 6 sample of the -- of the community, it makes it literally a 7 cross-section of the community. There's no particular 8 biasses in terms of over sampling of -- of older people or 9 younger people, men or women, anything like that. You're 10 just taking a random sample. 11 And we actually used the telephone directory 12 as the -- as the sample -- sampling frame. And we made sure 13 to include households from -- from within the City of North 14 Battleford, the Town of Battleford, as well as some of the 15 surrounding communities, so that we would have people who 16 would be -- have multiple exposures to water. 17 Recognizing that everybody mixes and mingles 18 as well, during the course of their day, in terms of work or 19 school or other activities. 20 Q: But again, in terms of legitimacy of the 21 survey, it's important to get people outside of say the City 22 of North Battleford, you need people from out -- outside 23 that? 24 A: That's right. 25 Q: And I understand, in terms of the

1 telephone survey, you said you used tele -- or the -- the 2 survey, you used telephone numbers. 3 And I -- I understand those were randomly 4 generated using a computer program? 5 A: There's a -- there's a telephone listing 6 that we had -- 7 Q: Right. 8 A: -- which was a computer based telephone 9 listing, and so we just -- we used the computer to help 10 randomly select from the listing. 11 Q: Right. 12 A: So they weren't randomly generating the 13 telephone number, but randomly selecting from the listing. 14 Q: Right. 15 A: And it was in fact a telephone survey, as 16 opposed to a mail survey or a person to person interview type 17 of survey, using a structured questionnaire. 18 And that structured questionnaire is provided 19 in the -- the package again, it's Appendix number -- Appendix 20 C in your report, which is page 62, and continues on to the 21 end of the report. 22 And we came -- we come up with that 23 questionnaire after careful input from both the province, as 24 well as the health unit. We also went to others in Canada 25 who have had outbreaks of cryptosporidiosis and asked to see

1 their questionnaires that they had. 2 But we also made sure that we had a good 3 understanding of some of the key risks within the community, 4 in terms of, for example, what kind of recreational water is 5 around, what kind of pools. 6 Obviously it was March/April, there's not a 7 lot of people swimming in -- outdoors, but having a sense of 8 what kinds of events were going on in the community. 9 So it has to be tailored to the community that 10 you're talking about. We can't just use a generic 11 questionnaire. Each one (1) has to be made up for -- for the 12 particular outbreak. 13 Q: But that is also based on your 14 understanding of the literature of risk factors that have 15 been identified for cryptosporidiosis? 16 A: That's right, we looked at the literature 17 as well when we're developing the questions to make sure that 18 we've -- we've covered off other risk factors. 19 Obviously municipal drinking water is one (1), 20 but certainly there are many others, including recreational 21 waters, camping, travel is another potential exposure, 22 drinking unpasteurized milk, contact with livestock. 23 Those kinds of things that we need to make 24 sure that we're asking about, so that we're -- we're covering 25 off all potential risks.

1 Q: And you talked about all the input you 2 got into the development of -- and design of the 3 questionnaire. That's important if you're -- if you're doing 4 a study to look at risk factors, the design of the 5 questionnaire therefore is very important, so to ensure you 6 capture the right information -- 7 A: That's right. 8 Q: -- is that correct? 9 A: That's right. Now what we decided to do 10 in this case was to use an adult proxy to answer the 11 questions, certain questions that were individual level 12 questions on those individual's behalf. 13 We -- we did decide to do that, rather than 14 try and get every single individual themselves on the phone. 15 So what we have here is household level data, which would be 16 generic to everybody in the household, as well as individual 17 level data, which is more specific to the individual. 18 And that could include some of their household 19 exposures, as well as their individual exposures. So what 20 that introduces there is the fact that it is an adult proxy 21 answering on behalf of those people. So, again, when we're 22 talking about when did that person's diarrhea start, then 23 that person would be -- would be recalling for another member 24 of the family. 25 Q: And that's a -- in a way, that's -- it's

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1 important to keep that in mind, that's a limitation to the 2 study? 3 A: That's a limitation. 4 Q: And in terms of risk factors, could -- 5 maybe using the questionnaire, can you run through the things 6 that -- that were identified as a potential risk factor for 7 cryptosporidiosis here? 8 A: Certainly. We -- 9 Q: That you -- that you saw data on? 10 A: Hmm hmm. We -- we wanted to know what 11 their municipal system -- what -- what kind of water was 12 their source water, was it a well, was it a municipal supply 13 and we made sure to include all of the water supplies that 14 potentially -- those in our survey sample could have been on. 15 We also wanted to make sure that we knew 16 whether or not they had some kind of home treatment device 17 that would actually be relevant for cryptosporidiosis or to 18 cryptosporidium and if they were doing any kind of other -- 19 other treatment to that water which may or may not help, if 20 they attended a daycare, if they worked in a long-term care 21 facility and those would be exposures that would give you 22 increased exposure to human fecal matter, drinking 23 unpasteurized milk, direct contact with livestock, animals in 24 the -- in the household and if those household animals had 25 diarrhea.

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1 We also wanted to narrow, in terms of the 2 individuals, if they had -- if they -- where they go to 3 school, where they go to work, whether or not they swim at 4 the North Battleford public pool, if they've been travelling 5 outside of Canada or the U.S. and, if they were away, how 6 long were they away for because we wanted to make sure that 7 we were looking at the time period when they were away, maybe 8 that period would mean that they -- they really weren't 9 relevant anyhow, but they weren't here. 10 If they had done any camping or fishing and 11 also any kinds of special events, if they were from outside 12 of North Battleford that might show that, well everybody who 13 came from outside went to this one (1) particular event, that 14 might make us more concerned about an event-related outbreak 15 as opposed to something that's in a water supply. 16 Q: And -- and keeping in mind that 17 transmission of crypto is fecal to oral, these are all types 18 of activities where a person might be exposed to that type of 19 transmission, whether water, food, for example daycare you 20 talked about -- 21 A: Yes. 22 Q: -- where there is substantial exposure. 23 A: That's right, it's always fecal-oral 24 transmission whether that feces came through water, food, 25 surfaces or another person.

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1 In addition, what we did then was, once we had 2 this questionnaire developed, then it was administered by 3 health unit staff after they had received training from Dr. 4 Rob Stirling, just to go through the questions, make sure 5 that they understood the questions, make sure they understood 6 how to administer the questions, that they weren't introduce 7 any kind of interviewer bias, there's another bias we worry 8 about in terms of them leading people on certain questions. 9 We want to make sure that they understood how 10 we wanted them to administer that and that training all took 11 place with all of them at once so that they all had a common 12 understanding of what we were hoping that they could do for 13 us with this. 14 Q: And -- and the importance there is that 15 the questions are being asked in a neutral way so that you're 16 not prompting a certain response? 17 A: That's right. 18 Q: That's the fundamental reason for the 19 training. 20 A: That's correct. 21 Q: Okay. 22 A: In addition, when we were asking 23 questions, when you look at the questionnaire, a lot of these 24 are going back in terms of time frame back to February the 25 14th and this, again, relates to the fact that, yes, we were

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1 concerned about the fact that there was the problem at the -- 2 the Surface Water Treatment Plant, but we couldn't be sure 3 that that was -- that was the problem when we were 4 administering the survey. 5 This took place between, I think it's the 3rd 6 and the 7th of May, that's in our report, but right at the 7 very beginning of May this was occurring so we really were 8 very early on, when we had this -- had this up and running 9 and completed. So it still remained to be seen, in our 10 minds, exactly what the exposure was. 11 So we asked people about illness going right 12 back to the 14th of February. The reason for that is we 13 wanted to make sure that we went far enough back so a full 14 maximum incubation period, if you will, back from the March 15 20th event at the Treatment Plant and then to also pick some 16 kind of a day that would, because we are asking people to go 17 quite back in time and that might be a bit of a -- of a 18 prompt for them in terms of their recall, so 14th being 19 Valentine's Day, we could ask about, you know, since 20 Valentine's Day, have you had this, what kinds of exposures 21 and that kind of thing. 22 Q: And -- and on that, as you said earlier, 23 you have knowledge of a particular event that may create a 24 risk factor. But the study is not designed simply to 25 investigate the one (1) particular risk factor, being the

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1 Surface Water Treatment Plant -- 2 A: No. 3 Q: -- it is designed to capture all these 4 other risk factors to make sure that the sample that we're 5 taking, we can draw some conclusions about the source? 6 A: That's right. And again, it's only going 7 to be able to tell us, yes, municipal wa -- drinking water 8 or, no, but -- from North Battleford. However, it's not 9 going to tell us which treatment plant was -- was the 10 problem. It'll only tell us, yes, we're concerned that the 11 source was municipal drinking water and then we go on to do 12 the next phase -- 13 Q: Right. 14 A: -- which was looking at the water quality 15 parameters. 16 Q: Okay. 17 A: The types of analyses we did, I'm going 18 to go through. We did a multi barrier regression analysis as 19 well as some spacial analyses to map these cases. 20 Q: And just on multi barrier regression, if 21 I might, what that involves is assessing a number of risk 22 factors and try to determine probabilities of illness -- 23 A: That's correct. 24 Q: -- from the risk factors. So you can 25 assign a probability to each risk factor and that gives you

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1 an idea what the possible source is. Is that -- is that 2 what -- 3 A: That's right. If you look on page 41, 4 there's table number 5. And we actually first of all do 5 something called uni-variant analysis where we compare simply 6 their case status to a number of different variables, one (1) 7 by one (1). 8 So on this table number 5 you can see that we 9 have the number of people who were primary cases who were 10 exposed to a certain thing, for example, North Battleford 11 municipal water supply. How many people who were not ill 12 were exposed to that water supply? And then how many were 13 not exposed to that. 14 Then we come up with a statistic called a 15 relative risk. And what that's going to tell us is that 16 people who had that exposure were "x" number of times more 17 likely to become ill than those who did not have that 18 exposure. 19 Q: And I'm afraid I -- I bumped you ahead on 20 this slide. Maybe we should go back and talk about the case 21 definitions before we -- 22 A: Okay. 23 Q: -- get into -- 24 A: Okay. 25 Q: -- into the how the analysis actually

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1 works. 2 A: Okay. Again, we have to come up with 3 case definitions. And in this case, we've got a household 4 level case definition. So a household -- an ill household 5 definition and we also have individual level definitions. 6 So an ill household was considered a household 7 where one (1) or more of the individuals met the definition 8 for a primary case which I'm going to show you in a moment. 9 A non ill household, there had to be nobody with -- with any 10 symptoms of gastrointestinal illness to be considered non 11 ill. 12 And other households that we have called 13 "other" were households where there were people who -- one 14 (1) or more people who had gastrointestinal symptoms but did 15 not meet the criteria to be a primary case. So you'll see 16 how that fleshes out then in a moment. 17 In terms of a primary case, this is a person 18 who had onset of diarrhea between March 21st and the time of 19 the survey, which, as I mentioned before was early May. In 20 this case, we were making them quantify their diarrhea, they 21 weren't called as having diarrhea unless they had three (3) 22 or more loose stools in a twenty-four (24) hour period. And 23 that was just to be very specific that they really had 24 clinical diarrhea. 25 We also wanted to make sure that they weren't

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1 from a household where somebody had diarrhea between that 2 March 14th to March 20th period because this person could 3 then in fact be secondary to somebody who was ill beforehand, 4 they might have something totally unrelated, but they have 5 clinical diarrhea. So we didn't want those people included 6 here. 7 Q: So that's why it's -- it's important to 8 exclude those people from the case definition because if you 9 included them, just based on the March 21st, they you're 10 testing a hypothesis that it's the problem at the sewage 11 treatment -- or the surface water treatment plant. If you 12 included those people, you would catch secondary cases that 13 would mislead you then, again, to the source. 14 That's why it's important to exclude the 15 secondary cases -- 16 A: That's right. 17 Q: -- is that right? 18 A: That's right. And so when we were 19 defining a secondary case, we tried to be fairly conservative 20 in that we -- we wanted to be -- a person -- a person who met 21 the criteria for being a primary case in that they're -- they 22 had this diarrhea, they also did not have a person in their 23 household who was ill before this time frame. And if their 24 symptom onset was greater than or equal to seven (7) days, 25 which is the median incubation period for cryptosporidium,

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1 after they're initial household case, we considered them to 2 be secondary. 3 We're going to be wrong on that some of the 4 time but the issue here is that, when we do our risk factor 5 analysis, we're only comparing people who are primary cases 6 versus those people who are not ill at all. And so we don't 7 want these secondary cases muddying our analysis because 8 those are people who became sick because of the risk factor 9 of ill person in your household. 10 We want to make sure we're just looking at 11 people who were the first ones to become ill and those people 12 who were not ill at all. 13 Q: And just before we move off that, you 14 picked March 21st. Just -- can you tell us why that was a 15 significant date for the case definition? 16 A: Again that would be their start date of 17 diarrhea. So same -- same -- before we were saying after 18 March 20th, but we say on March 21st or after, it's the same 19 thing. 20 Q: And -- and the similar reason, because 21 the minimum incubation -- 22 A: That's right. 23 Q: -- period is -- it can be as low as one 24 (1) day for cryptosporidiosis -- 25 A: That's right.

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1 Q: -- according to the literature? 2 A: That's right. I hate to give you any 3 more definitions, but here's just a couple more. 4 Again, we were looking at whether or not there 5 were confirmed, or if they were primary or secondary and they 6 actually had a positive stool specimen. And a control again 7 is a person who was -- had no symptoms of gastroenterit -- 8 enteritis. 9 They had to be completely healthy in terms of 10 their gastrointestinal symptoms. So -- 11 Q: Maybe before you go on, can you tell 12 us -- you touched on a little bit why we wanted to go back to 13 the 14th of February. 14 And just part of that, if you're looking at 15 the -- the event at the surface water treatment plant, that 16 you need a comparison before hand to exclude that event; is 17 that -- 18 A: That was really a -- 19 Q: -- fair -- fair to say? 20 A: -- not necessarily. We just wanted to 21 make sure that we were evaluating the risks for -- for a 22 reasonable enough period of time. 23 We didn't want to assume when we were 24 designing this, that the March 20th event was the event, 25 because we just really didn't know enough at that time.

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1 So by going back far enough we felt that we 2 could get a better sense of it. We were hearing anecdotes, 3 that oh no, people have had diarrhea for a while. So, we 4 wanted to make sure that we were ruling that out. 5 As it turned out we were able to use that in a 6 further analysis, looking at background rate for 7 gastroenteritis. But that wasn't the initial intention of 8 going back that far. 9 Q: Then the initial intention wasn't to 10 develop background rates, it was -- 11 A: No. 12 Q: -- okay. 13 A: No. So again, if we want to look at how 14 we did this -- this analysis, without getting too, too 15 technical, as we were mentioning before, we first of all 16 started out doing univari analysis, which are simply 17 comparing those who are ill and those who are not ill to the 18 different exposures. 19 And then -- 20 Q: And when you say those who were ill, 21 those are primary cases? 22 A: -- these are primary cases. So we're 23 looking at primary cases verus non ill individuals, and 24 whether or not they were exposed to this whole gamut of risk 25 factors.

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1 Q: And again, you're looking at table 5 on 2 page 41 -- 3 A: That's right. 4 Q: -- this -- the -- the gamut or risk 5 factors? Okay. 6 A: So what we come up with there are -- are 7 two (2) different statistics, one (1) is called a relative 8 risk, and this is going to give us an idea of the -- of the 9 odds of -- sorry, if the person has a particular factor and 10 that's a significant factor, then they are that many times 11 more likely -- they're that many times more likely to become 12 ill if you have that exposure versus if you didn't. 13 So for example, if you -- if you had been 14 exposed to North Battleford Municipal water supply, the very 15 first one (1), you were one point three six (1.36) times more 16 likely to become ill than if you were not exposed. 17 Q: Okay. 18 A: Now this is just in the simple one (1) by 19 one (1) comparisons. We also then had this thing that tells 20 us about whether or not that's specifically significant or 21 not. 22 And that's representative of the P value, and 23 basically the P value tells us the likelihood that this 24 association that we're observing is in fact not just due to 25 chance, it's a real -- it's really an association that we're

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1 seeing. 2 So when we're having an 95 percent CI, 95 3 percent confidence interval, that means that there's only -- 4 there's only a 5 percent chance that this was due only to 5 chance alone. 6 Q: Right. 7 A: We're 95 percent certain that this is a 8 real association. 9 Q: Okay. 10 A: Once we've done this step we then go on 11 and -- and we want to look at, well okay, these things just 12 looking at them independently have certain associations, but 13 are there some kinds of interactions or other things going on 14 that might make us make an erroneous conclusion. 15 And just to give you an analogy for that, for 16 example, we had an outbreak earlier on this year where we 17 were looking at salmonella and we kept on coming up that tofu 18 seemed to be the problem, and we were convinced it was tofu. 19 But when we got a little bit more information 20 later on, it turned out that there were peanuts found to be 21 contaminated. And in fact people had just simply not 22 recalled their peanuts or they hadn't been asked 23 systematically enough about peanut exposure. 24 And you can imagine that peanuts and tofu are 25 something that are eaten together. These were Asian

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1 population primarily, as well as the vegetarian population. 2 So many of those kinds of dishes are prepared 3 with those things together. But we were missing the fact 4 that it was the one (1) thing and not the other. 5 So if you put these things into a model, the 6 model helps to take care of those kinds of interactions or -- 7 Q: It's a -- 8 A: -- compounded -- 9 Q: -- it's a recognition that there's never 10 one (1) risk factor operating at a given time? 11 A: That's right. 12 Q: And then this is a method to -- to take 13 that into account to make some determination as to what is 14 the risk factor that is operative. Is that -- 15 A: That's right. 16 Q: -- a fair statement? 17 A: That's right. And -- and we address this 18 issue by actually doing our modelling in two (2) stages, just 19 to complicate things even further. 20 We looked at, first of all, a two (2) variable 21 analysis where we always included one (1) variable along with 22 age and the reason why we did that is that age is known to be 23 associated with -- there's always an impact of age on the 24 likelihood that you're going to get a certain enteric 25 infection, it doesn't matter if it's cryptosporidium or

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1 something else. 2 So we, first of all, started out doing -- 3 putting two -- two (2) variables in the model, that being age 4 as well as one (1) other variable and then we went on to a 5 final model. 6 When we're choosing which -- which variables 7 to put in this model, we make sure that they had a 'P' value 8 of -- of at least -- or, sorry, it had to be less than point 9 one -- zero point one (0.1) so that was kind of a 10 standardized convention in terms of a cut point for what you 11 decide to include in this modelling process. 12 Q: Okay. So the -- the first step of the 13 multi-barrier modelling is -- is a step to eliminate, in a 14 sense, some of the risk factors based on -- on what the 15 probabilities come up with; is that right? 16 A: Right. 17 Q: And so that, when you find that these 18 risk factors have a low probability, you eliminate them 19 because it's not likely that they're causing the -- the 20 outbreak; is that the step? 21 A: They -- they don't have -- if they aren't 22 statistically significant, we don't use them. 23 Q: Okay. And -- and you said the basis for 24 eliminating these risk factors was this point one (0.1) 'P' 25 value?

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1 A: That's right. 2 Q: Can you -- can you explain a little bit 3 to us -- 4 A: Yeah. 5 Q: -- what that -- what that means? 6 A: Normally -- the thing before, when -- 7 when we -- normally, when we look at statistical 8 significance, we're looking at a 'P' value of zero point zero 9 five (0.05) and that tells us that there's only a 5 percent 10 chance that this is due to chance alone. 11 Q: Right. 12 A: When we -- when we're actually choosing 13 what to put in the model, we actually even back that up a 14 bit, we say well we're going to include anything that, even 15 if there's a 10 percent chance that it was due to chance 16 alone, we're still going to include it and just look at it 17 just to be extra sure that that's not significant -- 18 Q: Okay. 19 A: -- and so we include that. And that's 20 just a convention sort of standard practice used in these 21 kinds of modelling procedures. 22 Q: Okay. 23 A: So what we come up with -- this is 24 another methodological thing. I almost think we should skip 25 to the results of that.

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1 Q: Why don't we do that and then we can go 2 back. 3 MR. COMMISSIONER: I think it would be 4 helpful, I mean I appreciate this is a very technical subject 5 and indeed the various charts and graphs are reasonably well 6 described in the report, but for the purposes, what was the 7 result of the cross-sectional study in general terms or where 8 did it fit in with the other studies that were performed? I 9 mean, I want some method of -- 10 MR. CHRISTOPHER BOYCHUK: She will tie 11 those -- all the studies in, if that's what you're looking to 12 do -- 13 MR. COMMISSIONER: Yes. 14 MR. CHRISTOPHER BOYCHUK: -- and -- and the 15 results, but I think it's -- 16 MR. COMMISSIONER: But I mean, even for 17 myself, looking at table number 5, I don't really understand 18 it at the moment, period. 19 MR. CHRISTOPHER BOYCHUK: Right. 20 THE WITNESS: Yeah, and the most important 21 one (1) is the multi-barrier one (1) so it's probably best to 22 present that, but we're going into a lot of detail on the 23 methods which -- 24 MR. CHRISTOPHER BOYCHUK: Okay. 25 THE WITNESS: -- it's -- it is very

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1 technical, which -- do you want me to go the multi-barrier 2 outcome or do you want me to finish going through -- 3 MR. CHRISTOPHER BOYCHUK: I think that's what 4 you're looking for is just to go to the outcome; is that 5 fair, Mr. Commissioner? 6 MR. COMMISSIONER: Oh, no, I'm not trying to 7 minimize the science involved, but I was wondering simply if, 8 as opposed to going down table 5 and dealing with each -- 9 THE WITNESS: Oh, I don't want that I -- 10 MR. CHRISTOPHER BOYCHUK: No -- 11 MR. COMMISSIONER: No -- 12 MR. CHRISTOPHER BOYCHUK: That's -- yeah, 13 we're past table 5, we're -- 14 MR. COMMISSIONER: Yes. 15 MR. CHRISTOPHER BOYCHUK: -- we've got the 16 next level. 17 MR. COMMISSIONER: I understand that, but is 18 there a summary of what, in general terms, does table 5 show? 19 MR. CHRISTOPHER BOYCHUK: I -- I don't think 20 there's a separate table because you have to set out all the 21 risk factors that you examine -- 22 THE WITNESS: Yeah, the summary comes as the 23 final model. 24 MR. COMMISSIONER: Well, I mean -- all right. 25 I'll just keep quiet and I'll wait until you're through with

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1 the presentation. 2 MR. CHRISTOPHER BOYCHUK: Okay. 3 THE WITNESS: I'll make sure I make it really 4 clear what the bottom line is. Should I -- I don't know 5 where you want me to go from here. 6 I don't -- probably shouldn't go into as much 7 technical detail on this -- 8 9 CONTINUED BY MR. CHRISTOPHER BOYCHUK: 10 Q: Well, why don't -- 11 A: -- background estimates. 12 Q: Why don't we just go to the results at I 13 think it's table 8, which is the summary of the -- that gives 14 you the table of -- 15 A: This one (1)? Okay. 16 Q: -- of the -- of what we found after doing 17 all this mathematics -- 18 A: Okay. 19 Q: -- and statistical analysis. 20 A: That's right. 21 Q: Okay. 22 A: Okay. So, after all of this complicated 23 modelling process, what we found is that people who were 24 exposed to North Battleford water in their home or at school, 25 so one (1) or the other, were one point five (1.5) times more

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1 likely to become ill than people who were not exposed in 2 either of those situations. 3 We then made a constant variable which would 4 have said, well, what if people were exposed to North 5 Battleford water both in their home and at work or school. 6 So people, I would presume, who would live in this community, 7 they were almost three (3) times more likely to become ill 8 than people who did not. 9 Now we often get things that will be 10 associated with illness and sometimes we'll get things that 11 are not. And contact with livestock was actually something 12 that we -- we -- we considered to be protective, if you will. 13 So what we actually found was that people who had had contact 14 with livestock, in general, if that's -- they're -- they're 15 generally exposed to livestock, were actually less likely to 16 become ill than people who were not exposed to livestock. 17 And then again, in terms of the age groups, as 18 we saw in the descriptive study, this again found similar 19 associations with these various age groups that people who 20 were ten (10) to fourteen (14) years of age were more likely 21 to become ill, almost three (3) times. People who were 22 twenty (20) to twenty-nine (29) years of age were almost four 23 (4) times more likely to become ill. And those who were 24 thirty (30) to thirty-nine (39) years of age were just a 25 little over two (2) times more likely to become ill.

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1 But certainly in terms of exposures, North 2 Battleford water consumption, whether it be in your home or 3 at school, was a significant risk factor for becoming ill. 4 Q: And of all the risk factors, was the most 5 significant risk factor? 6 A: Was the only significant risk factor. 7 Q: The only significant risk factor. 8 A: If we go back then to the -- the other -- 9 the methods for the other purposes which was to estimate 10 the -- the amount of illness that was -- that actually 11 occurred, in this -- in this situation, what we do is we -- 12 we look at what proportion of those that we surveyed were 13 actually ill? And we -- we want to make sure that we then 14 take out the background rate of illness that we could expect 15 to find. 16 And so this is where we were able to actually 17 get a measure of the background rate of gastrointestinal 18 illness, both through looking at those who became ill prior 19 to March 20th in our cross-sectional study, but we also went 20 to the literature to get some rates of gastroenteritis that 21 we would normally expect to find in any population. 22 There's been a couple of -- a number of 23 studies done and the ones that we used that we felt were most 24 relevant were one (1) conducted in Canada, one (1) in the 25 U.S. and one (1) in the United Kingdom.

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1 So we get a background rate of -- of 2 gastrointestinal illness, we subtract that rate from what we 3 call the crude attack rate, essentially, which is the 4 percentage of people who became ill in the survey. And then 5 we look at -- we actually do this specifically by age groups 6 but when we add them all up and get an overall population 7 estimate for how many people we believe actually became ill. 8 Q: Okay. And the importance you have to 9 knock out the background rate because that's -- that's 10 gastroenteritis, it's in the population at any given time, 11 that's the amount that's there. So that if you included 12 that, that would skew your numbers. 13 A: That's right. You want to make -- 14 Q: So you need to knock that out -- 15 A: -- that you've taken into account that 16 we're not over estimating and we in fact -- we used these 17 different -- four (4) different ways of calculating that 18 background rate so we'd actually get a range that we would 19 look at. 20 Maybe I should skip to that result -- 21 Q: Sure. 22 A: -- as well, now that I've presented that. 23 So when we did this kind of a community estimate, what we 24 found was that -- and we could only make these estimates for 25 the City of North Battleford and the Town of Battleford

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1 combined, because that was -- we had the best census data. 2 And what we estimated is that, somewhere 3 between fifty-eight hundred (5,800) and seventy-one (7,100) 4 people actually developed gastroenteritis as a result of this 5 outbreak, during that time frame. We were unable to come up 6 with similar kinds of estimates for outside the Battlefords 7 because of the fact that we didn't have the same kind of 8 census data or denominator data available to us. 9 But -- and if we look at the crude overall 10 attack rate, when we did our individual survey, about 38 11 percent of the individuals that we surveyed were ill with 12 gastroenteritis, during that time frame. 13 Q: Okay. Now, just -- just so I'm clear. 14 The -- the community estimate really is an extrapolation of 15 the attack rate less the background rate times the census 16 data that you used. Is that right? 17 A: That's right. 18 Q: So -- and what year was the census 19 data -- 20 A: 1996 data so we didn't have anything more 21 recent than that available to us. 22 Q: So you're relying, in terms of pop -- 23 general population in Battleford, per age group, on -- on the 24 '96 census data? 25 A: That's right. So if -- if the -- if the

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1 census has changed dramatically since 1996, then these 2 numbers could be off a little bit. 3 Q: Okay. 4 A: But again, it represents a range. 5 Basically just saying that we took, you know, a random 6 survey, 38 percent of the people were sick, then if we -- and 7 actually extrapolate that to the whole population. What does 8 that turn out to be? 9 And it turns out to be somewhere between 10 fifty-eight hundred (5,800) and seventy-one hundred (7,100) 11 individuals. 12 Q: Okay. 13 A: Just to give some of the descriptive 14 results that came out of the survey. There were a total of 15 two hundred and fifty-nine (259) households surveyed, 16 which -- so it's nine (9) more than we were counting on 17 getting. 18 Most of them were from North Battleford, 25 19 percent were from Battleford and the 9 percent were from 20 other communities. Of these there were actually 47 percent 21 of the households had somebody ill within their household. 22 So when you look at it in terms of what percentage of the 23 households became ill it was actually more. 24 When you look at how many were non ill, there 25 were 36 percent had nobody ill at all within that survey, and

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1 then there were forty-four (44) that were that other category 2 that I mentioned. 3 Q: And -- and again ill is defined to 4 include only primary cases, those people that had a date of 5 onset after March 21st -- 6 A: That's right. 7 Q: -- or after, and didn't have a family 8 member that was sick -- 9 A: That's right. 10 Q: -- within the -- the time period -- 11 A: It's -- 12 Q: -- before? 13 A: -- it's that household definition that I 14 gave -- 15 Q: Right. 16 A: -- earlier. 17 Q: Okay. 18 MR. COMMISSIONER: Is this particular slide 19 in your report as such? 20 THE WITNESS: It is in there, it's not -- 21 MR. COMMISSIONER: But it's not in point 22 form -- 23 THE WITNESS: -- in point -- concise like 24 that, no. 25 MR. COMMISSIONER: No.

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1 THE WITNESS: And in terms of the individual 2 level again, we obtained information then within those 3 households that turned out to be a total of six hundred and 4 fifty-two (652) individuals. 5 One hundred and ninety-six (196) were 6 classified as primary cases, 51 percent were classified as 7 secondary cases. And this is where I get this 38 percent. 8 So overall, with primary and secondary, we had 38 percent of 9 those surveyed had gastroenteritis at the individual level. 10 There were three hundred and eleven (311) 11 people who reported no symptoms and did not have any ill 12 members in their household. So that was the group that we 13 could draw on to use as controls. 14 When we plot these people out on a curve in a 15 similar manner to what we did before, again now these are 16 people who have just been telephoned by us, these aren't 17 people who are phoning into the health unit, it's not self 18 identified in terms of that -- there -- they've decided to 19 call the health department. 20 These are people who we've actually phoned 21 ourselves. And it's interesting to note that the trend is 22 exactly the same. 23 But again the increase occurs after the 20th 24 of March, it's really especially beginning about the 28th of 25 March, and we do see of course more secondary cases later on,

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1 or what we classified as secondary cases, which is what we 2 would expect, because of course they're secondary to those 3 who became ill first. 4 Here we've already gone through that. Now 5 this is another technical issue in terms of we wanted to -- 6 to see what -- what could we do to really help us feel more 7 confident that the March 20th event was indeed significant. 8 Certainly when you look at the information it 9 looks like the trend shows that people are becoming ill after 10 that time, but we thought, is there any kind of modelling or 11 statistics that we can apply to this to -- to suggest the 12 significance of that event. 13 And so what we did was we basically did 14 further multi-variant modelling, using different data sets, 15 different variations. 16 So we did the initial one (1) that I've 17 described. We then did one (1) where we put in everybody who 18 was sick anywhere between February 14th. And then we also 19 did another one (1) where we actually randomized their 20 exposure. 21 And so just looking at various different 22 methods for trying to get a sense of whether or not that 23 March 20th event was important. And we looked at that thing 24 called the relative risk, as you saw before, to see whether 25 or not that was influenced by those people being included in

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1 the analysis. 2 And what we found was that when those people 3 were included, there was really no impact on the odds ratio. 4 We would have expected if the water was the issue, that that 5 association would have actually strengthened. 6 So if people who were -- who were included in 7 the model and they were those people before March 20th, if 8 water was their risk factor, then that -- that statistic 9 should have gone up and it did not. 10 So that again helps to support the hypothesis 11 that the malfunction at the -- of the -- of the solids 12 contact unit was a primary factor in allowing those 13 cryptosporidium oocysts to enter the drinking water. 14 Again we -- we also wanted to do some mapping 15 then to look at where people were -- where people were 16 located within the town in terms of their residence, and if 17 there was any kind of a trend towards certain parts of town 18 having more people who were ill than other parts of town. 19 If their -- if their risk of becoming ill 20 increased in any particular direction within the town, and -- 21 or the City of North Battleford. 22 And what we found was that the areas in red 23 are where the -- the risk was increased, is that the risk of 24 becoming ill was increased for those living in the southern 25 and eastern portions of the city, as opposed to those living

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1 in the northwestern portion. 2 Now, of course, we always have to consider 3 when we look at this kind of information that, while this is 4 based on people's location of residence, obviously people 5 don't stay home all the time, they're exposed in multiple 6 different locations so we have to keep that in mind when 7 interpreting these results. 8 But the other thing that can be helpful about 9 this and this is where we -- we would love to have some kind 10 of modelling of the actual water system is to way, well, is 11 there some reason that this part of town is receiving more of 12 a particular type of water than another part of town. 13 And what we have been told anecdotally, when 14 we were speaking with officials, was that the surface water 15 treatment plant tends to serve more of that side of town so 16 we would expect that we would see a higher increased risk of 17 illness there if, in fact, that is true. 18 Q: So this modelling was to, again, test 19 your hypothesis that the March 20th event in the solid 20 contacts unit was significant? 21 A: It's really just show if -- if there is a 22 geographic or a spacial trend in terms of where the illnesses 23 are occurring. How that relates to the March 20th event, 24 because of -- of knowing the water distribution system and 25 where it goes, that's really for people who have that

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1 information to interpret. 2 We -- in Walkerton, for example, we ourselves 3 actually did an entire model of the entire distribution 4 system within Walkerton and then were able to look at this 5 kind of information with respect to how water flows and what 6 the proportion is from the different wells, et cetera. 7 We didn't have that kind of information 8 available to us here and we were told that there were others 9 who were going to be doing that so we didn't want to be 10 repeating that work. 11 Q: So -- but for the purposes of your 12 modelling, assuming that the information you received from 13 the City of North Battleford as to where the water is 14 distributed through the system from the surface water 15 treatment plant and from the groundwater treatment plant, 16 does that serve to reinforce your hypothesis that the problem 17 was at the surface water treatment plant? 18 A: That's right. If -- if that's true, that 19 the surface water treatment plant serves more of these -- 20 this area of the city, then that helps to support that the 21 surface water treatment plant was more likely the problem. 22 And that's it for that study. So moving on to 23 the final part, which was the environmental review, this was 24 not any kind of an in-depth analysis where we were looking at 25 all the functionings of the plant or anything along those

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1 lines, we -- we are not engineers so we are really looking to 2 find out what kind of water quality parameters we could look 3 at with respect to our other information to give us a sense 4 of what kinds of factors might have contributed to the 5 contamination of the -- of the water supply. 6 We also made sure to look at all of the water 7 treatment plants that we were concerned about and that did 8 include looking at the Battlefords -- or the Town of 9 Battleford Water Treatment Plant because, as I mentioned 10 before, when we first arrived, we weren't clear on exactly 11 which water supply we were talking about. 12 So basically the approach was that we had a 13 review of the different water treatment operations, we 14 collected whatever information we could in terms of finish 15 water turbidity, the percent settling of the solids contact 16 unit was information that was provided to us, again, by the 17 city, water volume contributions from each of the different 18 plants and the distribution system water quality. 19 So, by that, there were information on the 20 bacterial water quality, as well as the -- the -- also 21 chlorine residuals was the other part. 22 Q: And those were reviewed with respect to 23 all the water -- three (3) water treatment plants, the Town 24 of Battleford, the groundwater treatment plant and the 25 surface water treatment plant --

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1 A: That's right. 2 Q: -- for the City of Battleford? 3 A: And information was obtained. So the -- 4 the areas where there no significant findings was that we 5 found no irregularities in terms of what was given to us with 6 regards to the groundwater treatment plant, either in the 7 city or the town. 8 In addition, when we looked at the bacterial 9 water quality, in particular here I'm commenting on North 10 Battleford distribution system from January until April 2001, 11 there were no abnormalities in either of those areas, 12 bacteria or chlorine residuals, everything was -- was 13 interpreted to us as being within expected values. 14 Where we do see a problem is in terms of the 15 solids contact unit, which as you -- as you understand was 16 having some routine maintenance starting on the 20th of March 17 and what we have here is the -- the time on the bottom and 18 percent of settling which is their -- been explained to me as 19 being their -- their measure of the ability of the unit to 20 remove particles from the water so its ability to filter 21 particles out. 22 And this -- what I recall from my notes is 23 that it was supposed to be somewhere in the neighbourhood of 24 10 to 12 percent. But I would leave it to others to correct 25 me if I'm wrong on that but it certainly should be somewhere

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1 up in that range. 2 What we see here is that after the 20th that 3 basically goes down to zero (0) and continues to be like that 4 a few days after the 16th, probably about the 18th there. 5 And then slowly starts to come up. 6 Q: And I understand that the data for this 7 graph was provided to you by the City of North Battleford, is 8 that right? 9 A: Well through the water treatment plant 10 and city officials. So they're kind of -- I'm not too clear 11 how the division of powers are there -- 12 Q: Okay. 13 A: -- but it seems to me that they were 14 both -- 15 Q: Okay. 16 A: -- providing that kind of information to 17 us. 18 Here we have some finish water turbidity. And 19 again, turbidity is a measure of the particles in the water 20 so we can imagine that if, in fact, what we're seeing with 21 the solids contact unit is occurring, that the amount of 22 particles then that are getting through are going to 23 increase. 24 And this is information that we obtained from 25 SERM which shows us the -- the turbidity and NTU's along the

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1 Y axis, with the maximum turbidity highlighted in the darker 2 colour and the average in the sort of lighter greenish 3 colour. 4 I do need to point out that apparently once it 5 got to one (1) -- that one (1) could be the maximum or it 6 could be even a little bit higher. They didn't record above 7 one (1) was what I was told so I don't know the precise 8 estimate on those dates. 9 However, basically, the importance of what 10 this is telling us is that after that solids contact unit, we 11 can see that there was a -- a rise in turbidity. So that 12 just shows the impact that having that unit out of -- out of 13 operation had on the quality of the finished water. 14 And here's where we put these all together. 15 Now I recognize you won't be able to see all of the words but 16 you've seen these graphs before. And here what we have is 17 the -- the onsets of illness for people within the Battleford 18 service area. On the top graph with the surface water 19 treatment plant bar going down there on the 20th. And we've 20 got the precautionary drinking water with the red bars going 21 down on the 25th. 22 Our next graph that we have there is the 23 pharmacy A data which the -- the time frame of it 24 corresponded to our date scale on the -- on the X axis, 25 percent settling and then the turbidity. And basically what

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1 this is telling us is that we see this -- this rise in 2 gastroenteritis that is fairly dramatic occurring after the 3 20th and it seems to correspond in time to the same time 4 frame when this solids contact unit was not working and the 5 turbidity in the finished water was going up. 6 So helping to suggest that, in fact, what 7 caused this increase in -- in gastroenteritis which was due 8 to cryptospodorium was the fact that this was not working 9 during this time period which left the water vulnerable to 10 that kind of contamination. 11 I'm going to skip this slide because I've been 12 asked to because this has been removed from the package. So 13 going to our overall conclusions, we conclude basically that 14 the Battlefords area experienced an outbreak of waterborne 15 crypsporidiosis in the spring of 2001, that there were an 16 estimated fifty-eight hundred (5,800) to seventy-one hundred 17 (7,100) people from the Battlefords it affected, along with 18 hundreds more from other communities and -- and provinces. 19 The outbreak was most likely, according to all 20 of our evidence, suggests that the shutdown of the solids 21 contact unit left the system vulnerable to contamination from 22 the -- the river surface where it was drawing from. 23 This contamination most likely came from 24 faecal material that would have been upstream from the 25 surface water intake and it basically shows us very strongly

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1 the need for a multi barrier approach to protecting our 2 municipal water supplies. 3 MR. CHRISTOPHER BOYCHUK: And that's the 4 PowerPoint, Mr. Commissioner. If you like, we can go to 5 cross-examination. I don't have any follow up questions 6 right now. 7 MR. COMMISSIONER: Well, that's very good, 8 thank you. I think we're very close to the lunch hour so I 9 would suggest that we adjourn for lunch now. And I should 10 mention, I suppose all counsel are aware that this witness 11 wants to be done today, because she has a plane out first 12 thing tomorrow morning. And we want to accommodate that so 13 I'm not guessing that there's more than an afternoon of 14 cross-examination here. And if anyone has a different view, 15 perhaps you could let us know. Mr. Priel? 16 MR. TED PRIEL: No, sir. I don't -- I don't 17 think we'll be quarrelling an awful lot with the science of 18 this witnesses evidence. 19 MR. COMMISSIONER: All right. Sure, well 20 then we'll -- we'll adjourn till the normal time of 2:00 p.m. 21 and continue at that time. Thank you. 22 23 --- Upon recessing at 12:20 p.m. 24 --- Upon resuming at 2:00 p.m. 25

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1 MR. COMMISSIONER: All right, perhaps we'll 2 resume the afternoon session at this time, and Mr. Boychuk's 3 concluded and, Mr. Priel, the microphone is yours. 4 MR. TED PRIEL: Thank you, sir. 5 6 CROSS-EXAMINATION BY MR. TED PRIEL: 7 Q: Good afternoon, Dr. Ellis, my name is Ted 8 Priel, and my partner Mr. Stevenson and I represent the City 9 of North Battleford. 10 Doctor, I gather that your report was prepared 11 for the Province of Saskatchewan? 12 A: Yeah, we basically were called in on a 13 consultants capacity, so it went to the province as well as 14 the health unit. 15 Q: Okay. But the -- in the final analysis, 16 you did your report for the province? 17 A: As our primary people who invited us in, 18 but of equal importance to us is the health unit as well. So 19 they -- they receive things accordingly. 20 Q: Was your client the province or the 21 health unit? 22 A: Well it's not that easy. We were called 23 in by the province to assist the health unit. 24 Q: Okay. 25 A: So it's in succession. And when we're

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1 here we are reporting directly to the Medical Officer who -- 2 local, the local Medical Officer of Health. When -- when Dr. 3 Rob Stirling is here, his responsibility is to Dr. Gerhard 4 Bonade. 5 Q: When I went through the -- the -- the 6 health documents that were disclosed by the -- the Department 7 of Health with respect to these proceedings, I came across 8 a -- an oath of allegiance that was sent to you by the -- the 9 province. 10 Was that something that you received? 11 A: I received a copy of what they normally 12 send out for people -- what we were just talking about, 13 ensuring confidentiality among people dealing with data. 14 But it was just sent as an example. 15 Q: All right. 16 A: I'm assuming that we're talking about the 17 same thing, because I don't have the document that you're 18 referring to. 19 Q: Okay, but was that -- did you sign an 20 oath -- a form of oath of allegiance? 21 A: No, that was not a requirement they asked 22 me to. 23 Q: All right. 24 A: It was just to show me some sort of an 25 example.

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1 Q: All right. Okay, so that -- that your 2 view is that your report was prepared for both the province 3 and for the health district? 4 A: That's correct. 5 Q: All right. Now a great deal of time was 6 spent this morning talking about the solids contact unit and 7 settling percentages and things of that nature. 8 You'll agree with me, Dr. Ellis, that -- that 9 regulators in provinces, to your knowledge, don't regulate 10 settling percentages in solids contact units, and water 11 treatment plants; right? 12 A: My understanding is that each province 13 has guidelines that they set out their water quality 14 parameters and different monitoring procedures and different 15 methods of treatment required, depending on the source of 16 water. 17 Q: Okay, perhaps you didn't understand my 18 question. 19 And my question was whether or not to your 20 knowledge, provinces regulate settling percentages in solids 21 contact units? 22 A: I don't have the knowledge to know if 23 that's one (1) of the parameters -- 24 Q: Have you ever heard of it being done? 25 A: -- I've never heard of it before, and in

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1 reading for example, the Ontario Drinking Water Guidelines, I 2 haven't seen that there. 3 I haven't read the Saskatchewan guidelines. 4 Q: You haven't? 5 A: No. 6 Q: Okay. So that if I were to suggest to 7 you that they -- in Saskatchewan, the Municipal Drinking 8 Water Quality Monitoring Guidelines and the Municipal 9 Drinking Water Quality Objectives, do not regulate settling 10 percentages in solids contact units, you wouldn't be able to 11 disagree with me? 12 A: No. 13 Q: Okay. And if I were to suggest to you 14 that what is regulated are turbidity levels, would you agree 15 with me on that? 16 A: Yes, I would. 17 Q: Okay, and if I were to suggest to you 18 that in Saskatchewan the turbidity level that is required is 19 one point oh (1.0) NTU, in treated water would you agree with 20 me on that? 21 A: That tends to be typical. 22 Q: All right. 23 MR. COMMISSIONER: But Mr. Priel, this 24 witness is not a water expert or a regulator. I mean I -- in 25 fairness, there are going to be witnesses where you can make

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1 this point. 2 And I know for a fact that they don't 3 settle -- there's no regulations dictate settlement and the 4 like in the -- in a -- so, I mean the witness is -- we 5 qualified her as an expert epidemiologist and now we all of a 6 sudden are trying to tap her knowledge on regulation. I'm 7 not trying to protect the witness, I'm just saying it's 8 really so far out of her field that it's really not very 9 meaningful to me and -- 10 MR. TED PRIEL: Well, then, My Lord -- or Mr. 11 Commissioner, if -- if all of this lady's report that in any 12 way relates to things outside her field are totally -- 13 totally ignored by you, I don't have a particular problem 14 with it, but she spends a lot of time in her report talking 15 about such things as turbidity levels and talking about such 16 things as -- as settling percentages and talking about solids 17 contact units and talking about what should be done to 18 protect the -- the public with respect to cryptosporidium in 19 these kinds of plants. I think I must talk to this witness a 20 little bit about that, Mr. -- Mr. Commissioner. 21 MR. COMMISSIONER: All right. I just wanted 22 to indicate that certain things speak for themselves and, of 23 course, the regulations are one (1) of the things that speak 24 for themselves -- 25 MR. TED PRIEL: Thank you --

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1 MR. COMMISSIONER: -- and carry on. 2 MR. TED PRIEL: Thank you, sir. 3 4 CONTINUED BY MR. TED PRIEL: 5 Q: Dr. Ellis, let me just take you for a 6 moment and this -- this relates in some respects, Mr. 7 Commissioner, to -- to your last comment, to the conclusion 8 of your -- of your report and, as I read it, what you say is 9 that a thorough review of sewage inputs, both human and 10 animal, into the North Saskatchewan River and water treatment 11 systems -- 12 MR. COMMISSIONER: What page are you at, Mr. 13 Priel? 14 MR. TED PRIEL: Page 57. 15 MR. COMMISSIONER: Yes. 16 17 CONTINUED BY MR. TED PRIEL: 18 Q: And water treatment systems of 19 communities utilizing this source are warranted to minimize 20 the risk of gastroenteritis from the consumption of 21 contaminated drinking water; that's -- that's your 22 conclusion. 23 A: Yes, it is. 24 Q: Now, as I understand the situation, you 25 were the -- the person who was organizing the study that was

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1 done here in North Battleford? 2 A: I was in charge of supervising the -- the 3 two (2) people that were here in the field and I'm the head 4 of the section that -- that does these kinds of things so 5 that was my job to be the lead on that. 6 Q: Dr. Aramini and Dr. Stirling were here in 7 the field doing work? 8 A: That's right. 9 Q: Not that what you were doing wasn't -- 10 A: We were working hard too. 11 Q: Please don't get me wrong. 12 A: No. 13 Q: Now, as I understand it, on the 24th of 14 April, a document was sent from your -- from -- from Health 15 Canada to the City of North Battleford dealing with 16 cryptosporidium? 17 A: The 24th of April? 18 Q: Yes. 19 A: I have no knowledge of that document; can 20 you show me the document? 21 MR. TED PRIEL: Yes. Could I have you bring 22 up document 102726 on the screen please? If I might just 23 provide the witness with a copy of it, sir. 24 25 CONTINUED BY MR. TED PRIEL:

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1 Q: Had you seen that document before I 2 showed it to you here, Dr. Ellis? 3 A: No, I haven't. 4 Q: Okay. 5 A: I'm wondering who sent this to the -- who 6 in Health Canada -- 7 Q: Okay. 8 A: -- they would have accessed this from. 9 Q: All right. I -- I don't know, I just 10 found it on the -- on the documents. 11 A: Okay. 12 Q: But perhaps what I could do is -- is to 13 just speak to you just a moment about it. You -- you do 14 acknowledge that this came from Health Canada? 15 A: Actually, you know, in looking at this 16 right now, it looks to me that this is from a website, this 17 is -- this must have been pulled off the Health Canada 18 website because -- 19 Q: Okay. 20 A: -- it has -- the whole top part is all 21 referring to our website documentation so they must have just 22 simply pulled that off the Health Canada website and there 23 would be a fax sheet prepared by the Laboratory Centre for 24 Disease Control, which is what they used to call the group 25 that we're with now, about cryptosporidium.

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1 Q: All right. Now, I notice that the -- it 2 refers to the incubation period for cryptosporidiosis of one 3 (1) to twelve (12) days with an average of seven (7). 4 A: Hmm hmm. 5 Q: Which is, of course, what you've told us, 6 but it speaks also, Doctor, of an infectious dose of one 7 hundred thirty-two (132) organisms and I -- I gather that -- 8 that what the -- what that means is that a dose of one 9 hundred thirty-two (132) organisms would infect 50 percent of 10 the population? 11 A: Yes. 12 Q: All right. And you have told us in -- in 13 your report that, in your opinion, an infectious dose is ten 14 (10)? 15 A: That's another number of the literature. 16 And there are numerous different opinions in the literature. 17 This particular reference comes from a study that was done 18 on, I believe, human volunteers. 19 But, you know, some people will even say as 20 little as one (1) -- one (1) oocyst, that that's in a very 21 ill person. So it all comes down to the individual and ten 22 (10) is -- is another number that -- 23 Q: Does -- I'm sorry, go ahead. 24 A: Ten (10) is another number that's in -- 25 that's in the literature as well and you're going to find a

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1 range of opinions in the literature. 2 Q: All right. Does -- does the -- the 3 infectious dose, being either a hundred thirty-two (132) or 4 ten (10) or twenty (20) or fifty (50) or whatever, does that 5 in any way affect the conclusions that you came to in your 6 report, doctor? 7 A: No. And that's -- that's -- an 8 infectious dose, like you say, for 50 percent of the 9 population but there's obviously -- there's something like 10 ten (1) would be a minimum to -- we're comparing apples and 11 oranges there a little bit. 12 Q: Now doctor, Dr. Aramini and Dr. Stirling 13 were here in North Battleford fairly soon after you got the 14 call, correct? 15 A: That's correct. 16 Q: And you indicated to us when you -- when 17 you were introduced that your field of expertise is, first of 18 all, as a -- a doctor of veterinary medicine, I gather? 19 A: That was my first degree. 20 Q: Right. And then as an Epidemiologist, 21 with respect to which you have a -- a doctorate degree? 22 A: I've a masters degree in Epidemiology. 23 Q: I see. And you have a doctorate, do you? 24 A: I'm a doctor of veterinary medicine. 25 Q: Okay.

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1 A: I don't have a PhD. 2 Q: All right. Now, I gather also that 3 you -- you -- you have no knowledge, training and expertise 4 in the engineering field? You've told us that. 5 A: No. 6 Q: And you have no knowledge, training and 7 expertise in water treatment -- waste water treatment? 8 A: What we've learned is -- is -- having 9 interpret -- understanding how to interpret the water quality 10 parameters that are of relevance to human health outcomes. 11 So if things like understanding what the implications of 12 turbidity being too high, it's certainly something that I 13 understand. 14 Q: All right. 15 A: And what bacteria in the water or 16 chlorine residual is certainly something that we can 17 appreciate. We do have to rely on experts who are working on 18 theses -- these investigations as well, who are evaluating 19 the water treatment facilities to get their input on, okay, 20 well exactly what is the purpose of this solids -- solids 21 contact unit? What's the interpretation of the percent 22 settling. 23 And then we -- we look at, okay, well how is 24 that relevant, then, to the human health data? So it's just 25 putting other pieces of information in comparison to the

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1 human health outcome data that we're collecting. 2 If we were collecting information on rainfall, 3 it doesn't mean that I have to be a rainfall expert to then 4 be able to compare that information to have that impact on my 5 interpretation of -- of what the impact of rainfall would 6 have been, for example, on a situation like this, which we 7 used in Walkerton. 8 Q: You're too sensitive, doctor, I haven't 9 got to all of those points yet. 10 A: Okay. Well, I just want to make it clear 11 that we -- we -- we -- we use other information, other 12 parameters from other disciplines to help us to better 13 understand the information that we're getting on the human 14 health outcome. 15 Q: Something happened on, as I understand 16 it, the evening of the 26th of April? Dr. Aramimi and Dr. 17 Stirling, whoever was here, got some information that 18 influenced how you looked at this study? Is that correct? 19 A: Dr. Stirling was here and we just got 20 some more information that we -- we took into account in 21 designing the -- the -- the study -- 22 Q: What information did you get? 23 A: That was when we obtained information 24 regarding the solids contact unit having been down -- 25 Q: From whom --

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1 A: -- for a period of time. 2 Q: From whom did you get the information? 3 A: That would have been information that 4 would have been obtained in a meeting that Dr. Stirling would 5 have been at along with other officials from the health 6 department. 7 Q: Okay. 8 A: From the -- I'm assuming from the City of 9 North Battleford or from SERM. Actually I believe SERM 10 was -- was the provider of -- 11 Q: Right. 12 A: -- that information. 13 Q: SERM provided you with the information? 14 A: Yes. 15 Q: Okay. Now, did -- did Dr. Aramini or Dr. 16 Stirling themselves review the -- the -- the data from the 17 Water Treatment Plant Number 2, the surface water treatment 18 plant? 19 A: Dr. Aramini arrived on the 29th which was 20 a Sunday and he was the one that went through all of the 21 water data. So that would have been one (1) of the pieces of 22 information he would have looked at to -- in terms of 23 gathering his information. 24 Q: And is Dr. Aramini an engineer? 25 A: No, he's not.

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1 Q: Does he have training, skills and 2 knowledge and experience in water treatment and waste water 3 treatment? 4 A: No, he -- he has done a lot of 5 epidemiological research, however, relating to water quality 6 parameters and human health outcomes. 7 Q: Would it be fair to say, Dr. Ellis, that 8 your report relies to a very significant extent upon 9 information that you and your co-authors received from SERM 10 and the Department of Health, with respect to the operation 11 of a surface water treatment plant here in North Battleford? 12 A: That one fourth (1/4) part of the -- of 13 the report relies on that information, but the remaining 14 three quarters (3/4) did not. 15 Q: I -- I -- I appreciate that, and that -- 16 that's a fair comment. 17 Dr. Ellis, with respect to information that 18 you received concerning people who were ill, did you and your 19 co-authors have access to the original health information? 20 For example, laboratory information. Or did you get 21 summaries of that information from the Department of Health 22 and from the District Health Board? 23 A: It depends on specifically which 24 information. Some of it we saw -- we had directly, but then 25 we wanted things to be in data bases that we could then

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1 analyse. 2 So in many cases it was the final data set 3 that we would have in the course of time seen some, for 4 example, of the lab slips, but maybe not all of the lab 5 slips. 6 We would have seen line listing forms, we 7 would have seen completed questionnaires. In fact, we saw 8 all of the completed questionnaires. 9 So it depends on which data you're -- you're 10 referring to. 11 Q: All right. Which data -- what original 12 data did you have? 13 A: We would have had all of the -- the 14 cross-sectional study data. That was all -- all of that data 15 was -- was inputted by us at our office. 16 And then the other data from the -- from the 17 line listing forms, that was all put into data bases, either 18 at the province or at the health unit, and then provided to 19 us with the -- the nominal information, the names all 20 removed. 21 Q: Dr. Ellis, I'd like to just take you back 22 and -- and talk a little bit about -- about some of the -- a 23 couple of things that you mentioned in your report. 24 First of all, you point out that -- and fairly 25 so, that cryptosporidium parvum is a protozoan parasite that

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1 became recognized as a human pathogen in 1976. 2 A: Hmm hmm. 3 Q: Right. So before then it wasn't 4 recognized as a human pathogen? 5 A: No. 6 Q: If you accept for the moment that the 7 solids contact unit was installed in -- in this plant here 8 in -- in North Battleford in about 1980, would you agree with 9 me that it's highly unlikely that anyone ever recognized when 10 it was installed, that it might be instrumental in removing 11 the parasite cryptosporidium from the water? 12 A: I think that's a fair statement. I think 13 much of the industry didn't take note of this organism until 14 the big outbreak in Milwaukee in 1993. 15 Q: All right. 16 A: And most trade journals that you'll find 17 will reflect that. 18 Q: And cert -- and certainly a small central 19 Saskatchewan community like North Battleford would hardly be 20 expected to be familiar with that kind of problem before -- 21 A: In 1980 -- 22 Q: -- March of this year? 23 A: -- when they -- as I said, I-- I have 24 been exposed to through my work, numerous trade journals from 25 the American Waterworks Association, for example.

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1 And certainly since 1993 there's been an 2 extensive research and research dollars poured into this 3 problem in terms of addressing this in water treatment 4 plants. 5 So, no, I wouldn't expect that any water 6 treatment plant in Canada wouldn't be aware of the problem. 7 I would -- I would hope that all of them would be aware of 8 it, because I know that it's been extensively researched in 9 the water industry since that very, very large outbreak, over 10 four hundred thousand (400,000) people. 11 Q: Right. Now, doctor, when you -- when you 12 prepared your report, initially you had a -- you had a date 13 in mind other than the 20th of March, that is, when you -- 14 when you first began looking at this problem, you had a date 15 in mind other than the 20th, 21st of March, did you not? 16 A: We didn't have any particular date in 17 mind. We were -- we were concerned that -- we know, okay, 18 people started becoming ill, the first lab reports were 19 sometime early April, I can't remember the exact date, so we 20 wanted to make sure we were going back far enough that was 21 very quickly, as you can appreciate, the next day or the same 22 day that Dr. Stirling arrived that we heard this March 20th 23 date. 24 But we didn't have a particular date, we just 25 wanted to make sure that we were studying a relevant time

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1 frame relative to what we knew was when lab confirmed cases 2 began to be confirmed, recognizing that lag time I described 3 and people actually showing up as lab confirmed versus 4 becoming ill. 5 Q: Would it be fair to say, doctor, that -- 6 that what -- what you got from SERM was information that, in 7 SERM's view, the problem had been created as a result of the 8 solids contact unit being taken out of service, when it was 9 put -- put back into service, it was not operating to an 10 optimal level? 11 A: It sounded like it was a potentially 12 critical factor. 13 Q: Well, was that the information that you 14 got from SERM. Did I fairly describe the information that 15 you got from SERM? 16 A: I wasn't present at that meeting so what 17 I know are -- are the facts as opposed to the presentation of 18 the facts. 19 Q: Doctor, you authored the report. 20 A: I coauthored the report -- 21 Q: All right. 22 A: -- there are six (6) authors -- 23 Q: And tell me, what did SERM say to you or 24 your co-authors with respect to the solids contact unit that 25 caused you to focus on March 20th or March 21st as being a

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1 date that was important? 2 A: The facts that I know they provided were 3 that the solids contact unit, which was a critical piece of 4 equipment for filtration, was not working properly from the 5 20th of March to -- for approximately a month and so that 6 might have been a contributing factor, but we certainly, as 7 we -- as I mentioned in my initial discussion, we didn't rule 8 out looking for other sources because of that information. 9 Q: Now, doctor, can we go back to your 10 report for a moment and to the graphs that appear on page 52? 11 A: Hmm hmm. 12 Q: As I understand it, the -- the graph at 13 the bottom of page 52 is a graph that relates to the 14 turbidity level -- 15 A: That's correct. 16 Q: -- in the finished water at the surface 17 water treatment plant here in North Battleford? 18 A: That's correct. 19 Q: And you and I have both -- we agreed 20 earlier on that -- that the -- the Drinking Water Objectives 21 that are in place here in Saskatchewan and put in place by 22 SERM set a maximum level of turbidity at one point "O" (1.0) 23 NTU? 24 A: That's correct, that's my understanding. 25 Q: And you'll agree with me that nowhere on

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1 your graph does it show a turbidity level in excess of one 2 point "O" (1.0) NTU? 3 A: What I pointed out when I showed this 4 graph is that apparently the -- this was provided to us by 5 SERM, we just received this in September, and those values 6 where it is at one (1), we -- we were told we have to 7 interpret as being at least at one (1) or potentially above 8 because the measurement was not taken if it was above. If it 9 was -- if it was greater than one (1), it was apparently 10 recorded as one (1). 11 Q: Who told you that you had to take it 12 at -- 13 A: Commission Counsel actually. 14 Q: I see. And what else did he tell you -- 15 A: That was the only -- 16 Q: -- that had to do with turbidity level? 17 A: That was the only caveat that I heard 18 later on about this particular value of one (1) that I 19 understood about -- about that. But otherwise, this 20 information, as I say, was provided to us quite late in 21 preparing this report. We actually weren't even going to 22 include turbidity data because we didn't have this quality of 23 turbidity data available to us earlier on. 24 Q: Leaving aside the -- the -- the caveat 25 that Mr. Russell suggested that you should -- or Mr. Boychuk

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1 suggested that you should put on this information, you'll 2 agree with me, doctor, that your graph, the one (1) that's 3 presented in your report, that's here in evidence before the 4 Commission, doesn't show a turbidity level higher than one 5 point zero (1.0)? 6 A: The graph doesn't show that, no. 7 Q: Thank you. And doctor, did you -- who 8 prepared the graph that -- that's shown on your report here? 9 Did you do that or did someone do it for you? 10 A: Dr. Aramini took the data that was 11 provided to us by SERM and made the graph. 12 Q: And would it be fair to say, doctor, that 13 the -- the -- the higher levels of turbidity that, for 14 example, are shown in -- in a different colour, I don't know 15 whether it's -- it's -- 16 A: It's brownish. 17 Q: Right, it's a brownish colour -- 18 A: Brownish. 19 Q: -- that those levels may have been only 20 levels that were there for ten (10) minutes before the level 21 came back down? 22 A: They are indicated as maximums -- 23 Q: Right -- 24 A: -- so certainly that could be an 25 interpretation.

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1 Q: And if I were to suggest to you that when 2 SERM prepri -- prepared material that, on the basis of which 3 you -- you put this graph together, or your co-author put it 4 together, that they rounded the -- the turbidity levels off 5 to the highest level. Would you agree with that or do you 6 know? 7 A: I -- I can't state that. 8 Q: Okay. 9 A: They -- they gave us a maximum and an 10 average, so they're both presented there. 11 Q: Okay. Now, doctor, your report begins, 12 and pardon me if I look at the executive summary but being 13 basically lazy I -- I go there right away. You -- you talk 14 at first, on page 3, about your hypothesis. Correct? 15 A: Where -- where exactly are you looking? 16 Q: The bottom of page 3? 17 A: The bottom? Yes. 18 Q: And your hypothesis was that the 19 malfunction in the solids contact unit had a direct impact on 20 the quality of treated municipal drinking water in the City 21 of North Battleford and was the likely cause of the 22 waterborne gastroenteritis outbreak. Correct? 23 A: Yes. 24 Q: And what you did, and what your report 25 seeks to do, is to set out a hypothesis and they try to prove

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1 that hypothesis by various statistical information. Is that 2 right? 3 A: It sets out, as I mentioned before, the 4 first thing is we talk about that there's lots of 5 gastroenteritis which we saw through two (2) different 6 studies. The next one (1) was to say, what was the risk 7 factor? The risk factor was water, municipal drinking water 8 in North Battleford. 9 The next step is to say, if it was water, how 10 did it get into the water? And we know that there's two (2) 11 sources, surface and ground. The surface water plant was the 12 one (1) where there was a problem and temporally it all adds 13 up. 14 That's -- that's how we looked at it. 15 Q: Well perhaps what you could do then is 16 you could articulate for me what your -- what your hypothesis 17 was? 18 A: Well there are multiple hypotheses. 19 The -- the first thing is to -- is to prove the hypothesis, 20 was there an outbreak of gastroenteritis in the Battlefords? 21 That was easy to show. 22 The next one (1) is the hypothesis that it's 23 waterborne. So we -- we go about doing that -- proving that 24 hypothesis by doing an analytic study which in this case was 25 a cross-sectional study of the community.

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1 The next hypothesis is, what was the cause of 2 the contamination of the municipal drinking water. And 3 that's where we get into the solids contact unit. 4 Q: And in terms of the cause of the 5 contamination, did I articulate your hypothesis correctly? 6 A: Yes. 7 Q: Now, Dr. Ellis, were you consulted by 8 the -- the Department of Health or SERM with respect to the 9 protocol for the removal of the Boil Water Order? 10 A: They did send us some drafts of their 11 protocol, and we -- we looked at them. 12 Q: And would it be fair to say that you were 13 consulted with respect to that protocol about the middle of 14 May 2001? 15 A: I'd have to go back to my notes to look t 16 the exact dates. 17 Q: Do you have your notes with you? 18 A: Not the part that would tell me that, no. 19 Q: Okay. Well perhaps what I can do is help 20 you. Could I get you to put document 100278 up on the screen 21 please. 22 23 (BRIEF PAUSE) 24 25 A: Thank you.

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1 (BRIEF PAUSE) 2 3 It's hard for me to tell the date from here, 4 it's drafted on the 17th, to the date on this fax is June 5 6th. So, when exactly I was consulted, I can't remember. 6 Q: Would you agree with me, doctor, that 7 the -- the subject matter of this memo that is dated May 8 17th, 2001 relates to the -- the -- the protocol with respect 9 to the removal -- removal of the Boil Water Order? 10 A: Okay, yes, I'm sorry, now I'm recognizing 11 this document better. Yes, it does. 12 Q: All right. And this is -- this is a -- a 13 memo that you sent to who, SERM and the Department of Health? 14 A: No, we would have sent it to Dr. Benade. 15 Q: Okay. And, doctor, would you -- would 16 you read for me the first sentence in the third paragraph 17 under the heading, Monitoring please. 18 A: I'm sorry, the first sentence in the 19 third paragraph, the given -- 20 Q: Under the -- under the heading, 21 Monitoring. 22 A: Yes, the first sentence? 23 Q: The first sentence. 24 A: Okay, I'm sorry: 25 "The maj -- the major concern we have here

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1 that it was our understanding that the 2 North Battleford was meeting the 3 Saskatchewan objectives for safe drinking 4 water, given that it was not necessary to 5 monitor for giardia and cryptosporidium at 6 the time of the outbreak. 7 It would seem that additional monitoring 8 measures are needed to either prevent or 9 quickly detect a potential waterborne 10 disease risk." 11 Q: Thank you. 12 A: And can I explain the rationale behind 13 that statement? 14 Q: Well -- 15 A: Oh, I'm sorry -- 16 Q: -- what we'll do is -- is give you all 17 kinds of opportunity, Doctor -- 18 A: Okay. 19 Q: -- to explain yourself. But for the 20 moment I'd like you to tell me, did you get from SERM and the 21 Department of Health, the understanding that North Battleford 22 was meeting the Saskatchewan Objectives for Safe Drinking 23 Water, is that where you got that information from? 24 A: We would have gotten that information 25 from SERM I believe.

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1 Q: Okay. And, doctor, I'm -- I'm -- I'm a 2 little bit puzzled by your -- your choice of words here, 3 because you -- you say: 4 "The major concern we have here." 5 It's not just a concern, it's a major concern. 6 And why would you have a major concern that North Battleford 7 was meeting the Saskatchewan Objectives for Safe Drinking 8 Water, why would that be a concern for you? 9 A: We're -- 10 Q: I would have thought that -- 11 A: -- we're con -- 12 Q: -- you would have been pleased by that? 13 A: -- no, we're concerned that an outbreak 14 occurred, despite the fact that -- that those -- those 15 guidelines were being met. 16 Q: Right. 17 A: And so it showed us that there was 18 obviously a parameter that wasn't being taken into account. 19 Q: It showed you that there was a problem 20 with the objectives and the guidelines, didn't it? 21 A: No, because I think that the issue with 22 surface water is it has to be filtered; correct? In -- in 23 Saskatchewan, unlike in some other provinces, surface water 24 must be filtered. 25 So I guess to say -- and then it gets

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1 monitored using turbidity and bacterial water quality and 2 chlorination -- chlorine residuals. 3 So if the filtration isn't even in place 4 really to begin with, then can you still say you're meeting 5 the objectives? I'm not quite clear on that, but that's the 6 concern that you might be monitoring things, but it's not 7 even working, it's not even up and running in terms of the -- 8 the main -- the main barrier in the filter isn't even up and 9 running so -- 10 Q: Dr. Ellis, we've -- we've agreed, you and 11 I, that the Saskatchewan Water Quality Objectives require a 12 turbidity level of one point zero (1.0) NTU; correct? 13 A: Correct. I guess what I'm assuming as 14 well is that -- that the Drinking Water Guidelines also set 15 out that surface water must be filtered. 16 Q: Right. Now, are you -- well, did you 17 have any information that the Number 1, Number 2, Number 3 18 and Number 4 filters in the surface water treatment plant 19 were not operable; you didn't have that information, did you? 20 A: I understood that the solids contact 21 unit -- 22 Q: Right. 23 A: -- was not operating. 24 Q: You had -- you had information that one 25 (1) of the barriers in the -- in the surface water treatment

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1 plant was not working to full capacity. 2 A: It was not working, period. 3 Q: Oh, I see -- 4 A: Zero (0). 5 Q: -- you -- you had -- 6 A: My understanding was, when there's zero 7 (0) -- when the settling is zero (0), then that main barrier 8 that's filtering out particles, such as cryptosporidium 9 oocysts, was not in place, it was not working. 10 Q: And that was information given to you by 11 SERM? 12 A: That was my interpretation of -- 13 Q: The regulator here in Saskatchewan. 14 A: My understanding was that was the 15 concern. 16 Q: One (1) of the parties to this -- these 17 proceedings? 18 A: They didn't give me that directly, it 19 would have gone to one (1) of the colleagues, but in terms of 20 the interpretation, that was my understanding was, when 21 that's not working, we don't have the filtration in place 22 that we need. 23 Q: And in any event, on the 17th of May 24 2001, you -- you indicated to the Department of Health that 25 you had a major concern that North Battleford was meeting the

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1 Saskatchewan objectives for safe drinking water at the time 2 of the outbreak and that concern was driven, you say, by 3 what? 4 A: Our concern is that, despite the fact 5 that these -- what was being measured for the monitoring, it 6 seemed to be coming up with the results that they wanted, an 7 outbreak occurred in spite of that. 8 Q: Right. So that I guess, Dr. Ellis, one 9 (1) of the things -- other things you and I can agree on is 10 that settling in a unit such as the solids contact unit can 11 affect turbidity levels in the finished water? 12 A: Yes. 13 Q: And the lower the turbidity level, the 14 less chance there is of one (1) of these critters getting 15 through? 16 A: That's right. 17 Q: If we can call cryptosporidium oocysts a 18 critter. 19 A: Sure. 20 Q: Okay. And the higher the level of 21 turbidity, the greater the chance; is that a fair assessment? 22 A: That's right, but we don't know at what 23 turbidity. You might have -- you might have a perfectly 24 acceptable turbidity, but might have some oocysts going 25 through --

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1 Q: That's right. 2 A: -- especially if you're dealing with 3 something like surface water. 4 Q: That's right, that's right. So that 5 the -- the point of the matter is that, notwithstanding the 6 fact that my client was producing water that met the 7 Saskatchewan objectives for safe drinking water, some of 8 these oocysts got through the system; right? 9 A: Yes. 10 Q: And you're saying that that was a major 11 concern for you? 12 A: Yes. 13 Q: Now, doctor, when I read your report, I 14 believe it's at page 12, you make reference to the Milwaukee 15 outbreak -- 16 A: Hmm hmm. 17 Q: -- and you add a -- you added a statement 18 that -- that I thought was rather curious. Are you there at 19 page 12? 20 A: Page 12, yeah. 21 Q: Okay. Because what you say is the 22 Milwaukee outbreak -- in the Milwaukee outbreak, the 23 implicated water treatment plant was operating within 24 existing State and Federal regulations. 25 A: Yes.

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1 Q: That -- that was a gratuitous comment 2 that you made in your report; right? 3 A: Yes, and you'll find that in their 4 published paper on the subject as well. 5 Q: Right. Tell me, doctor, why when I read 6 your report from stem to stern do I not see a statement in it 7 that says North Battleford was meeting the Saskatchewan 8 objectives for safe drinking water at the time of the 9 outbreak; why didn't I read that? 10 A: We just didn't include that statement -- 11 Q: Why not? 12 A: -- we -- we do mention the bacterial 13 quality, that everything was okay there. But we just didn't 14 add that comment. It's probably -- 15 Q: I realize you didn't add it because I 16 can't find it. 17 A: Yes. 18 Q: But why didn't you add it, doctor? 19 A: I -- I'm not sure. We -- we could have 20 but we -- it wasn't that it was something that we consciously 21 chose to leave out. 22 Q: It only appears in a confidential memo 23 that you sent to the Department of Health -- 24 A: Yes. 25 Q: -- right?

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1 (BRIEF PAUSE) 2 3 Now, doctor, as I understand the situation, 4 there were a number of -- of confirmed -- laboratory 5 confirmed cases of cryptosporidiosis which apparently 6 occurred before the 21st of March of 2001. Is that a fair 7 assessment? 8 A: There are -- that's not -- that's not 9 totally accurate. 10 Q: Okay. Correct me if I'm wrong because 11 I -- I'm just a lawyer, I'm not a -- I'm not an 12 epidemiologist. 13 A: Okay. I'm just going to flip back to a 14 chart here, if I could. There was some people from within 15 the Battlefords health service area who -- whos reported date 16 of onset, and I believe I have the exact number in here, was 17 reported before March 20th, who had -- who were laboratory 18 confirmed. 19 Now, again, I have to -- let me just see how 20 many -- there -- there were ten (10) people. 21 Q: Is it ten (10) or twenty (20), doctor? 22 A: Ten (10) had -- okay, there were people 23 who had -- there were people who had diarrhea but then of 24 those who were actually lab confirmed, there were -- there 25 were ten (10) people.

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1 Q: So there were ten (10) lab confirmed 2 cases of cryptosporidiosis -- 3 A: Who -- who identified their symptom onset 4 date, themselves, remembering way back as before the 20th. 5 So -- but their test result was not taken until after that 6 time. 7 Q: Right. But -- 8 A: Okay, it wasn't that there were cases -- 9 lab reported cases that would have been taken, confirmed and 10 set off to the health department before the 20th of March. 11 Q: But you'll agree with me, doctor, that in 12 every -- every time one (1) of us goes to a doctor, much of 13 the information the doctor takes is subjective? And we will 14 say to the doctor, I began with these symptoms of diarrhea 15 on -- about a week ago or ten (10) days ago or whatever. 16 A: Certainly. 17 Q: So that in every one (1) of the confirmed 18 cases that you used to arrive at your report, in some 19 respects, they were based upon subjective information 20 provided to the medical person by the patient? 21 A: They're either provided to their 22 physician or to health unit staff directly -- 23 Q: Right. 24 A: -- but, yeah, absolutely they're -- 25 they're date of onset is what they recall but the vast

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1 majority of people, they're onset date was after March 20th. 2 There were some who were before -- 3 Q: There were some -- 4 A: -- and as I've mentioned before, they 5 could have been ill with something else. And then -- that 6 was causing gastroenteritis. We do get lots of other -- 7 other things that cause gastroenteritis that maybe was not 8 over before they became infected. 9 And so what we'll have is that they'll -- 10 they'll be lab confirmed later on but their onset date that 11 they report is much sooner in the future. And we ran into 12 the same problem in Walkerton. And it's a frustrating thing 13 'cause you can't sort out -- 'cause everybody doesn't go and 14 get a lab -- lab sample taken right when they become ill. 15 So we don't -- we don't know exactly the time 16 sequence of the illness starting, their cryptosporidium 17 infection. Was that the same thing? Was it 18 cryptosporidiosis that they had when they first became ill? 19 We really can't tell that with any certainty. 20 Q: Well doctor, the one (1) thing we can 21 tell with a great deal of certainty, though, is that there 22 were twenty (20) people in the North Battleford district, or 23 in -- where -- where were these twenty (20) people, by the 24 way? Were they within the North Battleford health district? 25 MR. COMMISSIONER: Where are we in this

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1 report at this point? Where are you referring to your ten 2 (10) -- 3 THE WITNESS: Page 23. 4 MR. COMMISSIONER: Pardon? 5 THE WITNESS: Page 23. 6 MR. COMMISSIONER: All right, thank you. 7 THE WITNESS: At the bottom paragraph. 8 MR. COMMISSIONER: I -- I was simply trying 9 to clarify that you have been referring to ten (10) persons 10 and Mr. Priel keeps referring to twenty (20) persons and I 11 guess I'll ask you now, where is your twenty (20) persons? 12 MR. TED PRIEL: My -- my twenty (20), Mr. 13 Commissioner, comes from -- there were twenty (20) people who 14 were suffering from diarrhea symptoms, as I understand it; is 15 that right, doctor? 16 17 CONTINUED BY MR. TED PRIEL: 18 Q: And of those twenty (20), ten (10) 19 confirmed positive after lab tests for cryptosporidiosis; is 20 that -- is that correct? 21 A: There were ten (10) lab confirmed, yes. 22 Q: All right, so ten (10) out of the twenty 23 (20) lab confirmed positive tests for cryptosporidiosis; 24 correct? 25 A: Were before the 20th of the March.

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1 Q: Right. 2 A: Yes. 3 Q: And again, doctor, as I understand it, 4 what you did was you took those twenty (20) people, ten (10) 5 of whom had tested positive, and you -- 6 MR. COMMISSIONER: Mr. Priel, I'm going to 7 stop you. I still don't see where this twenty (20) is coming 8 from? 9 THE WITNESS: Yeah, I'm not clear -- actually 10 I think there's more than twenty (20) people before that. 11 MR. COMMISSIONER: I mean I'm just trying to 12 follow your questions and I can't at the moment. 13 THE WITNESS: No, a hundred and nineteen 14 (119) people had diarrheal illness before, that's right. 15 16 CONTINUED BY MR. TED PRIEL: 17 Q: All right. 18 A: That's correct. If you look at -- Mr. 19 Commissioner, if you look at page 24 at figure number 3. 20 MR. COMMISSIONER: Hmm hmm. 21 THE WITNESS: You'll see all those people who 22 are in black, and those are the non outbreak related 23 diarrheal illness. 24 And there were a hundred and nineteen (119) 25 people, who of the one thousand and thirty-nine (1,039). No,

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1 I'm sorry, it's more than that. There were -- there were a 2 hundred and nineteen (119) people in addition to the one 3 thousand and thirty-nine (1,039), who had diarrhea, but their 4 diarrhea was before March 20th. 5 So therefore they did not meet the case 6 definition of after March 20th. They -- they're before March 7 20th, and the quest -- and among those -- that hundred and 8 nineteen (119), ten (10) of them were lab confirmed. 9 MR. COMMISSIONER: Okay. 10 THE WITNESS: So -- 11 12 CONTINUED BY MR. TED PRIEL: 13 Q: All right, so -- and -- and I'm sorry, if 14 I -- if I put it incorrectly, because I -- I thought I 15 spotted a figure -- 16 A: No -- 17 Q: -- of -- yeah, I thought I spotted a 18 figure of twenty (20) in your -- in your report when I -- 19 when I reread it again over lunch, Doctor. 20 So I apologize for -- for the confusion. 21 A: Yes, hmm hmm. 22 Q: But just to summarize then, we can -- we 23 can agree then, you and I, that there were a hundred and 24 nineteen (119) did you say? 25 A: A hundred and nineteen (119) people with

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1 onsets before March 20th. 2 Q: Right. 3 A: Who had diarrhea. 4 Q: Ten (10) of whom lab tested positive for 5 cryptosporidiosis? 6 A: That's correct. 7 Q: Right. And in terms of -- of your 8 report, you took those ten (10) people and you set them 9 aside; right? 10 A: No, we -- we -- we document them here, so 11 we -- we certainly considered that they were there, but 12 recognizing the fact that -- we have to decide, okay how -- 13 how do we explain that, when we've got all these other people 14 a hundred and -- a hundred and ten (110) people after the 15 20th that are all -- that are after the 20th, who are also 16 lab confirmed, in addition to nine hundred and twenty-nine 17 (929) others who are after the 20th. 18 And our trend is that we see it increasing 19 after the 20th. So this is -- so the fact that we've got 20 these ten (10) out here, it definitely is difficult to 21 decide, okay, how do we explain those. 22 And one (1) explanation is that, yeah, they 23 really did have cryptosporidium and they got it from some 24 place, and they were there before. 25 And that's a possibility. Another possibility

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1 is they -- they were -- they were wrong on their date of 2 onset and they fell on one (1) side of the 20th instead of 3 the other, and they were wrong. That's another possibility. 4 The third possibility is they are correct 5 about their date of onset, but that was when they had 6 something -- some other -- sort of you know, yeah, I had some 7 abdominal cramps back in February, but it's been continuing 8 on and they're still sick and they became ill with 9 cryptosporidium after the water became contaminated. 10 And we don't know where to put those people, 11 because none of them had their lab confirmation finished 12 before the 20th. They all -- they all came in after the 13 fact. 14 Q: Right. 15 A: So it wasn't that those people were lab 16 confirmed and it came in before that time period. 17 Q: And of course also it didn't fit with 18 your hypothesis that the solids contact unit was the problem; 19 right? 20 A: No, we wouldn't have -- the reason why 21 we -- why we have to consider those people as something else 22 is that it -- we're looking at that as being -- all of the 23 other evidence is suggesting that that date of March 20th was 24 a critical date. 25 For us to continue including all those people

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1 would not be correct. 2 Now when we also go to our -- our cross- 3 sectional study, where we actually do a systematic cross- 4 sectional evaluation of people in the community, and have a 5 more extensive interview with them, we don't see the same 6 thing, we don't get these people before the 20th coming up as 7 lab confirmed. 8 Q: Well, doctor, the 20th of March -- 21st 9 of March, that became a date of note to you, not because of 10 the lab results or the -- the health information, did it? 11 A: That's not true, we -- it became -- 12 Q: Well, did you have all the lab 13 information before you decided that March the 20th, March 14 21st was D-day? 15 A: We -- the -- the decision about March 16 20th is that -- of having to modify our case definition came 17 once we had looked at all the information together and we 18 thought we can't really possibly consider that all of these 19 people are related to the water because there is no evidence 20 to suggest that -- that the water was a contributing factor 21 back here and that's really something that you need to be 22 looking at, the cross-sectional study, you're in the 23 descriptive analysis or the case series. 24 So, when we look at that in terms of the risk 25 factor that we're evaluating, that time frame before, we

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1 don't -- we can't attribute the same kind of risk there to -- 2 to suggest that the water was, indeed, contaminated with 3 cryptosporidium before March 20th. 4 Q: Doctor, the -- you -- you made a comment 5 and you said how do I -- how do I explain these -- these 6 other cases if I don't follow my hypothesis; is that -- is 7 that a fair assessment of what you said? 8 A: It's not if they don't follow -- if they 9 don't -- if they -- they aren't fitting into this hypothesis, 10 we need to think of are there other possible explanations to 11 explain these people that would -- that would still be 12 consistent with the working -- the final hypothesis. 13 Q: And, of course, one (1) of those 14 hypotheses might be that somehow or other these people 15 contracted cryptosporidiosis and it may well have been from 16 the water treatment -- from the treated water here in North 17 Battleford and it may well be that the problem was not the 18 solids contact unit, but the problem was that the -- the 19 Guidelines and the Objectives set by SERM and the Province 20 Government are not strict enough; isn't that a possibility? 21 A: It was a multi-part question, I guess 22 I'm -- 23 Q: But you understood it, you're a pretty 24 intelligent lady? 25 A: In terms of those earlier people, they

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1 potentially could have been infected from something else, 2 some other source, contact with livestock, they have been 3 travelling, other kinds of things to explain why they became 4 ill. 5 It would still be quite a bit to have ten (10) 6 people though during that three (3) month period in that -- 7 in that service area -- in the Battlefords health service 8 area so that's where we wonder, well, how -- where do those 9 people fit in, in terms of -- in terms of that date. 10 But certainly, you know, we -- as I say, 11 we've -- this -- you run into these -- these cases where the 12 onset date is here, their lab confirmation date is over here 13 and so when did they really become sick with that pathogen 14 that was not diagnosed for months later; it's really 15 difficult to say. 16 Q: Okay. Doctor, there's only a couple of 17 areas more that I'd like to -- to speak to you about and what 18 I'd like to do is -- is perhaps have you turn to -- again, to 19 page 32 of your report, the various graphs that you have, 20 figure 18. 21 A: I'm sorry, page 32? 22 Q: Yes. 23 A: Or 52? 24 Q: 52, pardon me. 25 A: Okay.

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1 Q: The -- my trifocals don't work so well. 2 Doctor, the -- there are two (2) red dotted 3 lines that -- that go vertically through the -- through those 4 graphs -- 5 A: Yes. 6 Q: -- and the one (1) on the right is the -- 7 is what? 8 A: The PDWA or Precautionary Drinking Water 9 Advisory. 10 Q: Would you agree with me, doctor, that, at 11 the time the Precautionary Drinking Water Advisory was 12 issued, to all intents and purposes, the outbreak was on a 13 decline? 14 A: It was kind of right in the middle of 15 that -- that second peak, but it seemed that things were -- 16 were going in a downward trend from there. 17 Q: Right. You agree with me that things 18 were basically on a decline? 19 A: It's hard to know if that decline was due 20 to the Precautionary Drinking Water Advisory being issued -- 21 Q: That's a fair comment. 22 A: -- or -- we would hope it is -- or if it 23 was already, indeed, going down. 24 Q: But certainly if it had come earlier and 25 was to be effective, as you suggest it might have been, many

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1 of the people that became ill a couple of weeks earlier might 2 have avoided the illness? 3 A: If it had come earlier -- 4 Q: Earlier in the point of time? 5 A: Certainly. 6 Q: Okay. 7 8 (BRIEF PAUSE) 9 10 Doctor, just one (1) last matter. Did -- did 11 either the -- the Department of Health or -- or SERM provide 12 you or your -- your co-authors with any information with 13 respect to animals that may have been ill during the -- the 14 period March 20th to the end of April? 15 A: There were some reports of -- of dogs 16 with diarrheal illness at some of these cases homes. And in 17 all those cases, the -- the people's animal became ill at the 18 same time as they -- as the individual. So we can't conclude 19 that the animal passed it on to the person. 20 Q: What about livestock? 21 A: In livestock there were no reports of any 22 particular outbreaks of cryptosporidiosis in -- 23 Q: You didn't get any information like that? 24 A: There's no information like that that we 25 obtained, no.

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1 Q: Okay. Excuse me for a moment. 2 3 (BRIEF PAUSE) 4 5 Doctor, just to make sure that -- that you and 6 I are on the -- on the same page, when -- when I talk about 7 livestock, I was -- I was including horses. Did -- were you 8 intending that in your answer? 9 A: Yeah, I would consider livestock to be 10 any -- 11 Q: Okay. 12 A: -- farm animals, horses, cows, sheep. 13 MR. TED PRIEL: Thank you very much, Doctor 14 Ellis. 15 MR. COMMISSIONER: Thank you. We normally 16 take an afternoon break at about 3:30 so I'll invite the next 17 cross-examiner now if you're -- 18 THE WITNESS: That's fine. 19 MR. COMMISSIONER: -- fine with you, all 20 right, thanks. All right, Ms. Mitchell, are you -- 21 MS. SANDRA MITCHELL: Thank you, Mr. 22 Commissioner. 23 24 (BRIEF PAUSE) 25

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1 CROSS-EXAMINATION BY MS. SANDRA MITCHELL: 2 Q: Good afternoon, Dr. Ellis. My name is 3 Sandra Mitchell and I act for the Canadian Union of Public 4 Employees. And I just have a couple of very brief questions. 5 Firstly, did either Dr. Stirling or Dr. 6 Aramini advise you that either one (1) of them had met with 7 any of the employees who work at either the water treatment 8 plants or the sewage disposal plant? 9 A: Dr. Aramini was the one (1) who went 10 around and I believe that he was with somebody from the city, 11 as well as a consultant who they had hired in, I believe the 12 person who went with them. 13 Q: But when you say from the city, do you 14 mean it was an employee or a supervisor, or do you know? 15 A: Somebody named Randy, I'm sorry, his last 16 name is Stro -- 17 Q: Strelioff? 18 A: Strelioff, yes. 19 Q: Okay. Thank you. And -- 20 MR. COMMISSIONER: Ms. Mitchell, could you 21 bend that mike down a little bit at this point? Thank you. 22 MS. SANDRA MITCHELL: It's Mr. Priel's 23 height, it's not my -- my height. 24 MR. COMMISSIONER: That's right. 25 MS. SANDRA MITCHELL: Or lack thereof.

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1 2 CONTINUED BY MS. SANDRA MITCHELL: 3 Q: Did either Mr. -- or Dr. Stirling or Dr. 4 Aramini advise you that -- let me try and be clear about 5 this, we have had introduced as exhibits, Dr. Ellis, a -- 6 a -- an exhibit titled C-5 which is handwritten notes made by 7 the operators who work at the plants? 8 A: Okay. 9 Q: That's this document. And then we have 10 had introduced a -- another binder that's called C-6 which is 11 turbidity charts, the charts at the plant. So maybe you 12 could just review these and give me your professional 13 analysis, sorry I'm kidding. 14 A: Oh, good. 15 Q: In the next five (5) minutes. In any 16 event, did either Dr. Stirling or Dr. Aramini advise you that 17 while the turbidity charts -- you've referred to a meter that 18 only goes up to one (1), it's set at one (1), that was your 19 advice and it's -- it stands as good advice. 20 But did either Dr. Stirling or Dr. Aramini 21 advise you that in Binder C-5, that is the handwritten notes 22 made by the employees. There is a meter at the plant that 23 goes up to a hundred (100), and they record their handwritten 24 notes from that meter that goes up to a hundred (100). 25 So that there is in fact in Exhibit C-5, a

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1 record of the turbidity levels on the finished water coming 2 from that meter; did you know that? 3 A: I can't say that I was aware of something 4 called C-5, or that there were these handwritten notes. What 5 I understood in terms of their turbidity, was there was some 6 kind of a wheel that recorded data, and that it was not 7 something that was computerized, this is why our data was so 8 late in coming, is that initially somebody had attempted to 9 kind of eyeball an average estimate per day, which we didn't 10 realize was that kind of a cruder estimate. 11 And we understood from SERM that this was 12 better quality data to be able to include in the report. So 13 that's my understanding of the mechanisms in which the 14 turbidity data is -- is captured. 15 Q: Thank you. My last question, Dr. Ellis, 16 is at page 13 of your report you refer to the Milwaukee 17 Guidelines, I don't think you have to look at them, you've 18 already been through them with Mr. Priel. 19 A: The Milwaukee outbreak you mean? 20 Q: No, no, the -- the guidelines saying that 21 the Milwaukee people were operating within the objectives or 22 guidelines in the United States during the outbreak in 1993. 23 And then Mr. Priel has referred you to a memo 24 where you -- you state that the concern you have here is that 25 North Battleford was also operating within Saskatchewan

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1 objectives. 2 So I'm interested in your professional 3 opinion, as a health person, whether or not you consider the 4 current guidelines or objectives to be adequate, from a 5 health perspective? 6 A: Given the fact that this outbreak 7 occurred with those guidelines being met. In terms of 8 those -- those -- those monitoring parameters, I guess what I 9 was trying to make the point before is that the fact that 10 this -- that a piece of equipment wasn't working properly, I 11 would assume would factor into whether or not that's truly in 12 compliance with the guidelines, but I'm not clear on that. 13 But certainly I know that in terms of 14 turbidity that the turbidity value that's -- that's in many 15 of the current recommended guidelines is under review. And 16 that's being done by numerous levels of government, including 17 a part of Health Canada that I don't work with directly. 18 So certainly it seems to me that some of these 19 values around turbidity, that I know are currently under 20 review, probably warrants some review there, since we -- we 21 have seen a situation like this where the -- where the -- 22 where the -- and also in terms of what it is that we're 23 monitoring. 24 It's one (1) thing to be monitoring these 25 things and doing these tests and measuring certain

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1 parameters, but when -- when you've got a piece of equipment 2 that's not working up to standard, that should be part of 3 what's factored in, in your interpretation of are we doing 4 what we need to do to protect the drinking water. 5 Q: Is Health Canada one (1) of the 6 departments that has these objectives or standards under 7 review at this time; do you know? 8 A: Well Health Canada has a section that -- 9 that rev -- that develops drinking water quality guidelines 10 with the Federal/Provincial Territorial Committee on Drinking 11 Water Guidelines. 12 And this is a sub-committee I believe, and I'm 13 not directly involved in that committee. So we set 14 guidelines and then the provinc -- the provinces take those 15 guidelines and put them into regulations. And those -- those 16 do vary across the country, in terms of how different 17 provinces implement those. 18 Q: Those are political questions we'll leave 19 for another day. 20 A: Yes. 21 Q: Thank you very much. 22 A: Thank you. 23 MR. COMMISSIONER: All right, Mr. Young...? 24 MR. GARY YOUNG: I have no questions for this 25 witness.

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1 MR. COMMISSIONER: Mr. Gabrielson...? 2 3 (BRIEF PAUSE) 4 5 MR. NEIL GABRIELSON: Thank you. 6 7 CROSS-EXAMINATION BY MR. NEIL GABRIELSON: 8 Q: I have a few questions based upon your 9 report itself, as opposed to the -- the overview that -- that 10 you gave us here this morning. 11 And I wonder if you could just turn to page 5 12 first of your report. 13 14 (BRIEF PAUSE) 15 16 I -- I think that on page 5 you point out that 17 you acknowledge the -- the dedication and hard work of 18 certain people, and obviously I think from that it's clear 19 that -- that you got a good deal of cooperation from a lot of 20 parties who were involved out here and are involved today; is 21 that correct? 22 A: Yes, we certainly did. 23 Q: And -- and you found that I think 24 somewhat different, I would suggest, than -- than some of the 25 work that you had to do at Walkerton?

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1 A: It was a very different climate. 2 Q: And presumably that assisted you in -- in 3 developing the hypothesis and the conclusions that you 4 reached here today, that -- the -- the overall spirit of 5 cooperation. 6 A: I think that the investigation overall 7 was very much facilitated by the open sharing of information 8 between all parties. 9 Q: Thank you. Page 11 of your report, you 10 point out -- approximately in -- in the first paragraph, 11 second-last sentence, you point out that -- that 12 cryptosporidiosis is a self-limiting disease in -- in normal 13 circumstances? 14 A: Under normal circumstances, people just 15 clear the parasite themselves without any repercussions, 16 long-term. 17 Q: And, once again, that would be different 18 than -- that in Walkerton as well, I gather, because the -- 19 the bacteria there obviously were -- were fatal in some 20 instances? 21 A: That's correct. 22 Q: And, presumably therefore, the -- the 23 degree of urgency, in terms of investigations and in terms 24 of -- of prevention, is not as -- as critical, I guess, as -- 25 as obviously if it's a more serious pathogen?

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1 A: I think that any time that we're 2 concerned about some kind of -- of pathogen in a water 3 supply, the degree of urgency is -- is really the same, but 4 certainly the -- the outcomes will be different. 5 We're always concerned about those 6 particularly susceptible in the population and so I think, 7 from my point of view when I'm investigating an outbreak, we 8 want to make sure that we're -- we're on it and I think that 9 the -- the pressure on you might be a bit different when -- 10 not really, I think that the urgency is the same when you're 11 concerned about something in the water. 12 Q: All right. And -- and, just moving down 13 on page 11 there, you refer to a study that was done in -- in 14 1991 and I -- I presume -- it was the last paragraph. I 15 presume that was to -- to point out that -- that 16 cryptosporidium is -- is widespread, I guess, to put it 17 bluntly? 18 A: Yes. 19 Q: It -- it was found in that particular 20 study in 80 percent of raw water supplies and 27 percent of 21 finished water supplies. 22 A: That's correct. 23 Q: And I gather that, to that extent, it -- 24 it didn't surprise you that there -- there would be outbreaks 25 in Saskatchewan because you had reported it elsewhere in

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1 your -- in your report here of widespread outbreaks in 2 British Columbia as well? 3 A: There have been a number of outbreaks 4 reported in -- in British Columbia, in particular in 1996. 5 Q: And -- and, once again, you mentioned 6 some in Ontario as well. 7 A: Ontario as well, yeah. 8 Q: Okay. And at page 12 of your report, and 9 in particular the last paragraph, last sentence thereof, you 10 report that -- that, in a review that you're aware of from 11 Ontario, there -- there are main probable sources of 12 infection were recreational water of 26 percent, contact with 13 livestock 21 percent, drinking water 17 percent and person- 14 to-person transmission is 15 percent. 15 A: That's right. 16 Q: And I gather that would be why in your 17 presentation here today you mentioned that, even though you 18 have a potential source, you can't rule out other sources 19 because it can be -- there is -- there is no one (1) specific 20 source, you can't put all your eggs in one (1) basket, you 21 kind of have to keep an open mind and -- and keep reducing, I 22 guess, the -- the potential possibilities before you come to 23 a final conclusion? 24 A: Yes, that's correct. 25 Q: I just wanted to take a minute too, if

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1 you would turn to page 54 of your report and the second 2 paragraph there, towards the bottom of it. 3 You talk about an estimated background 4 gastroenteritis rate of point three (0.3) episodes per person 5 year and then maybe if you just take a moment to explain what 6 that means in terms of -- of the -- the kind of the -- the 7 background and why it was important in your report? 8 A: Well, we used a background rate -- we -- 9 as we did those estimates and we -- we used four (4) 10 different background rates just to -- when we were 11 extrapolating to make sure that we were taking out those 12 people that we would normally expect to have gastroenteritis 13 over the course of -- of a year or actually specifically over 14 the course of the number of weeks that we were looking at. 15 So, when we use a background rate, for example 16 of point three (0.3) episodes per person per year, then 17 that -- that's one (1) estimate of how many people you 18 would -- or how many -- one (1) individual would have a 19 chance of having point three (0.3) episodes of 20 gastroenteritis in a year. 21 Q: Or to put it correspondingly, one (1) 22 episode every three (3) years; is that -- 23 A: Yes. And -- and then we -- we also have 24 these other rates from the literature where it was as little 25 as point two (.2) or as much as one (1). So that every

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1 person would have one (1) episode of gastroenteritis in a 2 year, anyhow, from whatever reason. 3 So when we use those background rates we have 4 to -- we have to subtract those from our -- what we call our 5 crude attack rates. And we have 38 percent of the people 6 that we've surveyed being -- having gastroenteritis. We have 7 to figure, okay, how much of that is in excess of the 8 background rate that would be expected? 9 And so that's where we eliminate those and 10 we're left with the balance. 11 Q: And -- and I guess the significance of 12 that is that every time you get an outbreak of 13 gastroenteritis, you don't automatically think everybody's 14 got cryptosporidiosis? 15 A: Oh, definitely not. If you have 16 gastroenteritis you don't necessarily assume that -- that 17 it's an outbreak or that it's cryptosporidium. And when you 18 have a lot of people with gastroenteritis or a few people 19 being reported, you have to have -- you have to know with 20 respect to your base line, are we truly in excess? 21 I mean the number one (1) step when you're 22 investigating an outbreak is to establish the existence of an 23 outbreak. Do we really have an outbreak? 24 Q: And I guess that was my final question 25 here. Having gone through the -- the data here and -- and

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1 you've seen the onset and the -- and the conclusion here, did 2 you have any concerns about the way the investigation of the 3 cases of -- of gastroenteritis or the ultimate conclusion as 4 to when the public -- the Boil Water Advisory and Order were 5 made that those ought to have been made earlier? 6 A: I didn't -- I didn't have that particular 7 concern when I was -- I wasn't here during that time. 8 Before, of course, before the 25th we weren't involved, I 9 wasn't getting any information. However, when the 10 information was reviewed to us in those initial 11 teleconferences, as to where the people, it wasn't apparent 12 that they were clustering all in one (1) location, the 13 initial ones that were lab confirmed. 14 Other ones came later. It sounded like what 15 we were seeing, excuse me, was the due course of -- of 16 identifying the existence of an outbreak. And then that 17 we -- that we then came to that point where on the 25th, the 18 Precautionary Drinking Water Advisory was issued. 19 Q: Thank you. Those are my questions. 20 MR. COMMISSIONER: All right. Mr. Tochor? 21 Oh, Mr. Hopley, I'm sorry. 22 23 CROSS-EXAMINATION BY MR. SCOTT HOPLEY: 24 Q: I just have a few questions. Now, with 25 respect to that reference in your report to the -- there's

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1 the chart showing the increasing average daily finished water 2 turbidity? Did your report do anything to control for 3 possible changes in the raw water turbidity levels? 4 A: No. We just had that information 5 provided to us. And really the whole point of including that 6 was just simply to show that there seems to be an impact that 7 occurred in terms of the turbidity or there seemed to be a 8 correlation in time frame that the turbidity seemed to go up 9 during that same time frame that the solids contact unit was 10 at 0 percent settling. 11 Q: Okay. 12 A: And that's all. 13 Q: Yes. So you didn't look at whether the 14 raw water -- raw river water turbidity increased? 15 A: No, we didn't have that information 16 available. 17 Q: Okay. Now, a crypto oocyst is a very 18 small organism, isn't it? 19 A: That's correct. 20 Q: Okay. Do you have any idea what -- what 21 level of contamination of -- of the oocyst would -- would it 22 take to have some sort of measurable effect on the turbidity? 23 A: No, I don't have that -- that 24 information. 25 Q: Okay. Am I correct in thinking that

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1 oocysts in -- in that point in the crypto life cycle, they 2 don't multiply when they're in the drinking water system, do 3 they? 4 A: No, they don't. 5 Q: Okay. And the -- the problem is, I think 6 it's fair to say, arose from crypto oocysts entering the 7 drinking water distribution system? 8 A: That's correct. 9 Q: Okay. 10 A: Coming out people's taps. 11 Q: Did your study do anything to look at 12 whether there were changing levels of oocysts in the raw 13 river water during the time period of your study? 14 A: No, and I don't know if there was anybody 15 actually monitoring oocysts levels in the river prior to that 16 time. The testing for oocysts in water is -- is not all that 17 great, is my understanding. So I don't believe anybody was 18 doing that. But we didn't take that into account. 19 Q: Okay, and so is it fair to say then that 20 your study couldn't -- or didn't control for whether the 21 problem was the result of some breakdown at the water plant, 22 as opposed to some huge introduction of oocysts into the raw 23 river water? 24 A: No, we -- we can't say -- I guess it -- 25 we have to assume that at any time this river could have

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1 oocysts going down it in varying concentrations, this is a 2 ubiquitous organism is what we were trying to point out in 3 the -- in some of the literature that we provided. 4 And so therefore whether it's high or whether 5 it's low, the -- the -- the drinking water plant is the place 6 that's the barrier to the distribution system to help control 7 for that and -- and you have to have the parameters in place 8 that controls for the -- the worst case scenario, that there 9 are high concentrations. 10 Q: Okay. Having said that though, I mean 11 there was no way to tell whether there was some before this 12 outbreak, that there was some dramatic change in the quality 13 of the raw river water? 14 A: No, we don't have that information. 15 Q: Okay, thank you. 16 MR. COMMISSIONER: All right, Mr. Tochor. 17 18 CROSS-EXAMINATION BY MR. MICHAEL TOCHOR: 19 Q: Dr. Ellis, I hope to be very brief. As I 20 understand your earlier testimony, Health Canada has a list 21 of reportable diseases? 22 A: That's correct. 23 Q: And cryptosporidium did not make it to 24 that list until January of 2000? 25 A: That's right.

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1 Q: Can you just briefly elaborate on the 2 criteria to make that reportable disease list? 3 A: Yeah, I don't have all of those here with 4 me, and I'm not involved in the sub-committee that looks at 5 that, but -- but just to give you an idea of how they go 6 about doing it, there's a -- a sub-committee on communicable 7 diseases that uses certain criteria to -- to decide, you 8 know, in terms of the population at risk, and a number of 9 different factors to come up with a score. 10 And then if it -- if it hits that score, then 11 it goes on the list and if it no longer does, it might be 12 taken off the list. So they -- they have a number of 13 different parameters of -- in terms of health outcomes and 14 other features. 15 Q: Would it be fair to suggest then, that 16 prior to January of 2000 it didn't appear to meet the 17 criteria to be on the reportable disease list? 18 A: No, I think it was under consideration 19 for a bit of time, and I -- I was trying to get a sense of 20 the history of that, because I was a little bit surprised 21 that it wasn't actually on it until 2000. 22 But a number of the provinces, they -- they 23 were on board a little bit quicker. And but really to be 24 useful at National Surveillance, all of the provinces have to 25 be reporting those -- those organisms. Have it on their own

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1 notifiable disease list, their own provincial list, and then 2 we have it on our national one (1), so that we've got the 3 data flowing to us. 4 So I know that for -- from some provinces, for 5 example, Saskatchewan I understand it was 1997 that it came 6 on. All the different dates I'm not clear on, but -- but 7 exactly what the process was or when it was first introduced 8 or being considered, I can't answer that question. 9 Q: But you do have knowledge that in 10 Saskatchewan it was on the provincial reportable disease list 11 in approximately 1997? 12 A: That's my understanding. 13 Q: Okay, roughly some two and a half (2 1/2) 14 or three (3) years prior to becoming on the -- the National 15 Reportable Disease -- 16 A: That's correct. 17 Q: -- list? 18 A: That's correct. 19 Q: The secondary -- it's likely a relatively 20 minor point. On page 11 of your report and it's paragraph 3, 21 there's mention in that report of a 1991 study, or it could 22 be two (2) studies by LeChevallier. 23 A: Hmm hmm. 24 Q: And very briefly, I understand that that 25 study was of fourteen (14) American States and Alberta, and

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1 it found eighty-seven (87) -- I'm sorry, there was 2 cryptosporidium found in 80 per -- 87 percent of raw water 3 samples and cryptosporidium in 27 percent of finished water 4 samples; is that right? 5 A: That's right. 6 Q: There's a couple of points I wanted to 7 make about the LeChevallier studies, and it's not indicated 8 in your particular report, but you've -- you've had 9 familiarity with the LeChevallier studies? 10 A: Yes. 11 Q: And I understand that in the studies by 12 LeChevallier, the average level of contamination was one 13 point five (1.5) oocysts per one hundred (100) millilitres of 14 water; is that fair? 15 A: I -- I can't remember the specific 16 numbers from the study. 17 Q: Do you have any reason to doubt that 18 approximate number? Or doubt that it was relatively a low 19 level of oocysts found per one hundred (100) millilitres of 20 water? 21 A: Yeah, without the study in front of me 22 I'd have a hard time commenting on that. 23 Q: You'd agree that most of the organisms 24 found and most of the crypto oocysts found were not viable? 25 A: That's correct, that's their second

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1 statement there. 2 Q: And in fact, only two (2) of twenty-three 3 (23) oocysts found were viable. Does that number seem to 4 ring a bell? 5 A: That rings a bell. 6 Q: I don't have the study here to present it 7 to you, but, in generalities, that's relatively? 8 A: It sounded like, while they did find 9 evidence, a number of them were not viable. 10 Q: And there were no reported outbreaks as a 11 result of the oocysts that were found in these studies; is 12 that fair? 13 A: That's right. 14 Q: And the LeChevallier study also dealt 15 solely with surface water treatment plants; is that fair? 16 A: That's right, if it's filtered. 17 Q: It did not deal with groundwater plants, 18 for example? 19 A: Not this particular study, no. 20 Q: And you're aware that there's different 21 studies -- Canadian studies by -- by Wallis (phonetic), for 22 example, that have different conclusions; is that fair? 23 A: There's certainly different numbers -- 24 various -- various numbers that are out there in the 25 literature.

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1 Q: There's a Wallis study done in 1996? 2 A: Yes, and I think that one (1) involved 3 both surface and groundwater; is that the one (1) you're 4 talking about? 5 Q: Yes. 6 A: Yes. 7 Q: And that was the Canadian study? 8 A: Yes, that's right. 9 Q: And that study found cryptosporidium in 10 3.4 percent of treated water samples; is that fair? 11 A: That's correct. We -- we chose to use 12 this reference because of the fact that these were surface 13 filtered -- filtered surface water sources. 14 Q: Oh, I see, the LeChevallier study was 15 devoted solely to surface water? 16 A: That's right, so it seemed the most -- 17 and we -- we were trying to find, in -- in that other study 18 that you're mentioning, how many of that three point four 19 (3.4) were from surface water versus groundwater and it's not 20 clear in the study. 21 Q: Mr. Gabrielson indicated, though, when 22 referring to the LeChevallier study that cryptosporidium is 23 widespread. 24 A: Yes. 25 Q: You certainly don't want to be seen as

202
  1  suggesting that 27 percent of treated water supplies are a
  2  public health risk; is that fair?
  3                 A:   No, that's correct and that would be the
  4  conclusion from that study because they didn't see any
  5  outbreaks during that time frame.
  6                 Q:   Okay.  I just wanted to ensure there
  7  wasn't any misinterpretation of that.  It's not to suggest
  8  that 27 percent of the treated water is a public health risk;
  9  that would be the wrong conclusion --
 10                 A:   No, it's not a public health -- that's --
 11  what we -- what they observed in that study was that there
 12  was not an observable public health risk from that high
 13  percentage.
 14                 Q:   And it would be a wrong conclusion to
 15  suggest that 27 percent of the water is a public health risk,
 16  it would be a wrong conclusion to draw?
 17                 A:   Yes.
 18                 MR. MICHAEL TOCHOR:   Thank you very much,
 19  doctor.
 20                 MR. COMMISSIONER:   Okay, thank you. 
 21  Mr. McDonald...?
 22                 MR. ROBERT McDONALD:   I have no questions of
 23  this witness, sir.
 24                 MR. COMMISSIONER:   All right.  Mr.
 25  Scharfstein...?

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1 MR. GRANT SCHARFSTEIN: I'll be brief, Mr. 2 Commissioner. 3 MR. COMMISSIONER: All right. 4 5 CROSS-EXAMINATION BY MR. GRANT SCHARFSTEIN: 6 Q: Good afternoon, Dr. Ellis, my name is 7 Grant Scharfstein, I represent some of those fifty-eight 8 hundred (5,800) or seven thousand (7,000) estimated people 9 that became ill with this outbreak based on your report. 10 I just have two (2) or three (3) quick 11 questions. Now, My Friend, Mr. Gabrielson had indicated and 12 talked about the urgency issue and the seriousness of an 13 outbreak of cryptosporidiosis. You would agree with me and I 14 think it's in your report that, in immuno-compromised people, 15 cryptosporidiosis can even be fatal; is that correct? 16 A: In some cases, yes. 17 Q: Now, there were, during the relevant time 18 period in North Battleford, three (3) or four (4) or five (5) 19 deaths that occurred and I'm wondering -- and -- and there 20 was an issue about whether cryptosporidiosis had any role to 21 play in that. 22 In your study, was that looked at by your 23 people as to whether it contributed to the deaths of these 24 individuals? 25 A: Nobody involved from our team was

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1 involved in reviewing the records of those individuals in 2 question. 3 Q: Okay. So you have no information in that 4 regard? 5 A: I have no information I can provide you 6 on that. 7 Q: If you would turn quickly to page 52, the 8 three (3) -- or the four (4) graphs that are indicated there; 9 I want to talk a bit about timing. 10 You may or may not be able to answer this 11 question, but, in your experience, when I look at the top 12 graph, the Date of Onset of Diarrheal Illness, I notice that 13 the peak appears to have occurred by my calculation on April 14 12th of 13th, I can't quite -- 15 A: That's our calculation too. 16 Q: But that's the date? 17 A: Yeah, we agree. 18 Q: The Water Advisory was put out on the 19 25th of April, I believe. In your experience, is that period 20 of time reasonable or are there many factors that go into 21 determining whether it should have been sooner or later? 22 A: There's -- there are numerous factors 23 that go into that. Often what we find is that outbreaks are 24 recognized or are beginning to be investigated that, when we 25 are able to plot these kinds of curves, it's at the peak;

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1 if -- I could show you a number of examples of other 2 outbreaks where that's exactly the case. 3 I think the -- the big thing that has to be 4 done, once you've got the concern, which I understand 5 occurred somewhere around that -- that date, is to be able to 6 compare what you have to -- to past data in terms of your 7 surveillance data, do we really have people all clustering in 8 one (1) location, rule out other possible sources. 9 Was there a common -- common event that all of 10 these people went to? What are -- what are all of the 11 other -- what are all the potential exposures that these 12 people could have had that were in common to result in their 13 infections? 14 Q: Based on the evidence that you've 15 obtained in your study, are you in a position to say whether 16 the time period between the peak, on the 13th of April, or 17 the 12th of April, and the 25th was a reasonable time within 18 which it took to issue the water advisory? 19 Are you in a position to say whether it could 20 have been sooner or should have been sooner? 21 A: I -- I don't feel in a position to make 22 that judgement. 23 Q: Okay. My -- my final question is, and -- 24 and just to make sure I fully understand and I think I do, 25 that in doing your study, is it your opinion that you've

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1 ruled out any other probably or possible cause of the 2 outbreak of cryptosporidiosis in North Battleford in this 3 time period, other than through the treated water? 4 A: We do believe that our cross-sectional 5 study helped to rule out all those other causes and all of 6 the evidence suggests that it was -- the water was the source 7 of the contamination. 8 Q: I have no further questions, Mr. 9 Commissioner. Thank you. 10 MR. COMMISSIONER: Mr. Russell, or Mr. 11 Boychuk, I'm sorry, do you have anything in re-examination? 12 Or -- ? 13 MR. CHRISTOPHER BOYCHUK: Just briefly, Mr. 14 Commissioner. 15 MR. COMMISSIONER: All right. 16 17 RE-DIRECT BY MR. CHRISTOPHER BOYCHUK: 18 Q: If you could turn to page 52 of the 19 graphs. And before we get to that -- before we get to that 20 I'll deal with the -- the confidential memo that Mr. 21 A: Yes. 22 Q: -- Priel put to you. And just -- just so 23 we're clear, the comments you were asked to provide were on 24 what circumstances should the emergency boil water order be 25 lifted for the City of North Battleford. This is what this

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1 memo pertains to, isn't that right? 2 A: If I can make this clear that this 3 memo -- we were asked to comment on their draft protocol for 4 the boil water advisory. We did make it clear to them that 5 we have no jurisdictional authority to decide whether or not 6 a local municipality should lift their boil water notice or 7 not. 8 But they wanted our input because we'd been so 9 involved and so these were some of the comments that we laid 10 out to them. So that's the context of the memo, just so you 11 understand. 12 Q: Right. That's the context of the memo. 13 You're asked to comment on a particular protocol. 14 A: That's correct. 15 Q: And that's what they're looking -- so 16 when you make the comment regarding monitoring, as I 17 understood your answer, you're saying, maybe we need to build 18 in some other safeguards before we lift the -- the emergency 19 boil water, other than just the existing standards. Isn't 20 that right? The monitoring standards? 21 A: Yeah. We're -- we're suggesting that 22 other -- other things need to be -- be monitored -- make sure 23 that the solids contact unit, for example, that settling is 24 adequate in order to do this. 25 But we did make it clear, I believe in the

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1 overriding e-mail that went with this confidential memo that 2 these are just our opinions, our professional input but not 3 any kind of jurisdictional -- we don't have any 4 jurisdictional authority to tell them they need to change 5 this. 6 Q: Right. And -- and one (1) of the things 7 you touched on, maybe in terms of monitoring, is, we should 8 check if we've got settling in our solid contacts unit? For 9 example, another thing, before you lift the emergency boil 10 water order, would be something that, given your experience 11 and the data you had, would be an important -- 12 A: Yes. 13 Q: -- thing to consider. 14 A: And that they're -- they're monitoring 15 that and that's into account. It's fine if the turbidity 16 is -- is within guidelines but if you have 0 percent 17 settling, then -- 18 Q: Okay. 19 A: -- that's probably not okay. 20 Q: And to deal with the implication that Mr. 21 Priel brought. In your report, your epidemiological report, 22 does the fact where the guidelines are met one (1) way or the 23 other, whether it's turbidity or chlorine levels or anything, 24 affect the conclusions or you need to have that information? 25 A: No.

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1 Q: You don't, do you? 2 A: No. 3 Q: And that's why you don't put the method 4 guidelines in here because it doesn't -- it -- it isn't -- it 5 isn't useful to your conclusion, is it? 6 A: No, it's not necessary -- 7 Q: It's not necessary. 8 A: -- it's not necessary to our -- 9 Q: Right. 10 A: -- conclusion. 11 Q: And another thing, I'd like to -- so 12 we're clear, SERM wasn't the only source as to what was going 13 on in terms of the operation at the surface water treatment 14 plant? 15 A: No, certainly the -- the officials from 16 the -- the city who were involved in the -- the drinking 17 water plant were also providing data. 18 Q: Pro -- and specifically, all the data 19 regarding settling came from the city is -- is -- is that -- 20 is that correct? 21 A: That's correct. 22 Q: Okay. And in terms of the turbidity 23 chart at the bottom, in terms of your conclusion, am I right 24 in saying that it isn't the absolute turbidity amounts. What 25 jumps out at you from the chart is the change in turbidity

210

1 levels, together, at the same time that the settling went 2 down? 3 A: Exactly. It's really just to show that 4 there -- that the turbidity seemed to have been influenced by 5 the fact that -- that this -- this contact unit was not 6 operating. 7 Q: Right. So whether it's one (1) NTU or 8 point NTU, that's not the important part, it's the change in 9 the turbidity, the increase -- 10 A: That's right -- 11 Q: -- is -- is relevant? 12 A: -- it seems it consistently at least 13 doubled if not quadrupled. 14 Q: Right, and -- and just to put Mr. Priel's 15 mind at ease, had you ever talked to me before you prepared 16 this report? 17 A: No. 18 Q: Or anyone at Commission Counsel? 19 A: No. 20 Q: And in fact I didn't get a copy of this 21 report until I met you for the first time, isn't that right? 22 A: That's right. 23 Q: And so any comments I might have had 24 about the circle charts and how they only went up, they're 25 not in this report are they?

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1 A: No. 2 Q: And the report was prepared before you -- 3 you heard that information? 4 A: That's right. 5 Q: Thank you. 6 MR. COMMISSIONER: Mr. Scharfstein. 7 MR. GRANT SCHARFSTEIN: I know that the 8 witness had used a PowerPoint program in her presentation, 9 but I don't believe that that's part of the exhibit that was 10 tendered, and I'm wondering whether that could be tendered -- 11 that PowerPoint presentation could be tendered as a full 12 exhibit in this matter, so that it's before everyone. 13 THE WITNESS: It is there, I think it is 14 there, isn't that tab 3. 15 MR. GRANT SCHARFSTEIN: Well I think -- but I 16 think the PowerPoint one (1) that you've given is a bit 17 different than the one (1) that's in the book -- 18 THE WITNESS: Yeah -- 19 MR. GRANT SCHARFSTEIN: -- there were a few 20 changes. 21 THE WITNESS: -- we had to strike that one 22 (1) slide and -- and the other one (1) -- we have to modify 23 it and my only -- because of the change this morning. 24 MR. COMMISSIONER: But otherwise what you're 25 saying is that the PowerPoint presentation is in --

212

1 THE WITNESS: It's in your -- it's in the 2 binder that -- 3 MR. COMMISSIONER: Yes, but I think it was 4 the section that was removed from my particular copy. I'm 5 not sure if it's removed from everyone's copy or not. 6 MR. CHRISTOPHER BOYCHUK: Actually to address 7 Mr. Scharfstein's concern, we're happy -- we've already made 8 arrangements with Dr. Ellis, to get copies of the disk 9 distributed to everyone, of her PowerPoint as amended. And 10 that what we would do is if -- if need be, I'm sure we can 11 just enter it as an exhibit once we get the disk from them, 12 if that's acceptable. 13 THE WITNESS: Sure. 14 MR. CHRISTOPHER BOYCHUK: And -- and I hope, 15 does that address your concern? 16 MR. GRANT SCHARFSTEIN: Yes. 17 MR. CHRISTOPHER BOYCHUK: Thank you. 18 MR. COMMISSIONER: Well all right then, it 19 seems like a reasonable time to take our afternoon break, and 20 thank you, Dr. Ellis, for all your work obviously in the 21 report and for appearing here today, thank you. 22 THE WITNESS: Thank you. 23 24 --- Upon recessing at 3:32 p.m. 25 --- Upon resuming at 3:50 p.m.

213

1 MR. COMMISSIONER: All right, Mr. Russell, 2 are we ready to proceed? 3 MR. JAMES RUSSELL: Thank you, Mr. -- Mr. 4 Commissioner, yes, we are. Our next witness is Mr. Frank 5 Hollmann, if he can be sworn. 6 7 (FRANK HOLLMANN, Sworn:) 8 9 MR. JAMES RUSSELL: Mr. Commissioner, we do 10 have a binder of documents to enter as an exhibit with this 11 witness, it's in conjunction with two (2) subsequent 12 witnesses, the materials appear in the same binder, but we 13 expect that these witnesses will be fairly consecutive, which 14 is why they have been placed that way; with your permission, 15 I'd like to -- I'd like to enter them. 16 MR. COMMISSIONER: Yes, please do. 17 MR. JAMES RUSSELL: And for the information 18 of -- of legal counsel, Mr. Commissioner, we have -- we have 19 removed from the binder that was circulated the materials 20 that were contained in tab 4; they are not entered in the 21 exhibit that we're entering with you. 22 We subsequently discovered from information 23 that came to our attention that the information in tab number 24 4 was best not put to this witness and we're reserving it to 25 put to a future witness so it is -- it's in the material that

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1 legal counsel received, but it is not in the exhibit. 2 MR. COMMISSIONER: All right. Well, then the 3 book, which is entitled -- well, refers to the three (3) 4 witnesses, Frank Hollmann, Peter Allen and Judy Szuch, will 5 be C-13 and minus tab 4. It's not in the official exhibit 6 either, I take it? 7 MR. JAMES RUSSELL: It is not, Mr. 8 Commissioner. 9 MR. COMMISSIONER: No. So, if and when you 10 get around to introducing the document that would normally 11 fit in there, just advise us and we'll insert it at that 12 time. Thank you. 13 MR. JAMES RUSSELL: That document may not 14 be -- is it your anticipation, Mr. Commissioner, that you 15 would like that documentation inserted in this binder? It 16 was our -- it was our plan to insert it in another binder 17 which would be for another witness. 18 MR. COMMISSIONER: Oh, well that's fine, 19 sure. 20 MR. JAMES RUSSELL: Okay. 21 MR. COMMISSIONER: C-13 for this particular 22 binder. 23 24 --- EXHIBIT NO. C-13: Binder referring to Frank 25 Hollman, Peter Allen and Judy

215

1 Szuch. Tab 4 has been removed. 2 3 EXAMINATION-IN-CHIEF BY MR. JAMES RUSSELL: 4 Q: You're Mr. Frank Hollmann? 5 A: That's correct. 6 Q: I understand that you were a Plants 7 Operator Level 3 for the City of North Battleford; is that 8 correct? 9 A: That's correct. 10 Q: And I also understand that you became a 11 full-time plants operator in 1995 with the city, but that 12 prior to that you had worked part-time at the job over a 13 three (3) year period; is that correct? 14 A: That's correct. 15 Q: I also understand that you completed your 16 Grade 12 education in 1978? 17 A: That's correct. 18 Q: You then spent time at university 19 studying biological sciences, but took no formal degree; is 20 that correct? 21 A: That's correct. 22 Q: Your education in water resources began, 23 I believe, with a diploma in Environmental and Water 24 Resources Engineering from the SIAST Kelsey Campus in 1988; 25 is that correct?

216

1 A: That's correct. 2 Q: Now, what kind of course was that Mr. -- 3 Mr. Hollmann, was that a full-time course or was it a 4 correspondence course? 5 A: No, it was a full-time course. 6 Q: And how many years did you have to attend 7 at the Kelsey Campus to complete that course? 8 A: Two (2) years. 9 Q: Two (2) years. And can you give us some 10 indication of the -- the material that you would be likely 11 to -- to have covered in that course as part of your 12 education in relation to water and waste water management? 13 A: In the first year, you'll -- you'll study 14 basic subjects such as calculus, drafting techniques, 15 physics, chemistry, environmental chemistry and, as the 16 course progresses, you become more specialized in areas of 17 water treatment and waste water treatment, hydrology, wells, 18 those type of courses. 19 Q: So is it a fairly -- is it a fairly 20 comprehensive course, in other words, when you come out of 21 it, you're in a position to -- to know about the basic 22 processes, the basic chemical components of both water and 23 waste water treatment by the time you have finished? 24 A: I'd say the basic processes, yes. 25 Q: Okay. I understand that you've also

217

1 taken the Western Canada Surface Water Treatment Course; is 2 that true? 3 A: That's correct. 4 Q: And when did you complete that? Was that 5 a correspondence course? 6 A: Yes, it was. 7 Q: And I think -- 8 MR. COMMISSIONER: You can pull that 9 microphone a little closer to you so you don't have to lean 10 forward each time, Mr. Hollmann. 11 THE WITNESS: Thanks. 12 13 CONTINUED BY MR. JAMES RUSSELL: 14 Q: Now am I right in assuming, Mr. Hollmann, 15 that in addition to that you took a separate waste water 16 treatment course as well? 17 A: That's correct. 18 Q: Now when did you do those two (2) 19 separate courses? 20 A: I believe the course -- the surface water 21 treatment course I completed in 1997 and the basic waste 22 water treatment course I believe was 1998. 23 Q: And did you complete those courses at the 24 Kelsey campus as well? 25 A: No, I didn't.

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1 Q: What kind of courses are they? Are they 2 correspondence courses? 3 A: The surface water treatment course is 4 a -- a correspondence course. And the basic waste water 5 treatment course is a course held in Saskatoon. 6 Q: And in terms of the content in those 7 courses, for instance, how would it -- how would it differ 8 from your basic Kelsey education that you had initially 9 taken? What did you -- what did you learn in addition to 10 what you already knew by taking those courses? 11 A: The surface water treatment course would 12 deal specifically with your plant and the operations of a 13 surface water treatment plant. It would, I believe it was -- 14 there were fifteen (15) lessons you'd go through and each 15 dealing with different aspects of the treatment plant and 16 processes. 17 The two (2) day treatment course dealing with 18 waste water was an overview of a basic waste water treatment 19 plant. 20 Q: Okay, now the -- the surface water 21 treatment course plant -- sorry, course, was that a two (2) 22 day course as well? 23 A: The surface water course? 24 Q: The surface water course -- yes. 25 A: No, that was a correspondence course.

219

1 Q: That was a correspondence course. Okay. 2 And you say you learnt the -- the basics of your -- of your 3 treatment plant. Do you mean a generic treatment plant or 4 the specifics of the plant you were working at in North 5 Battleford? 6 A: Both the generics and specifics of the 7 plant. 8 Q: And that would have covered both surface 9 water and groundwater? 10 A: No, that wouldn't. Only surface water. 11 Q: Only surface water, okay. So you were 12 given an opportunity during the course of -- of taking that 13 course to discuss issues peculiar to the -- the surface water 14 plant in North Battleford? 15 A: Yes. In -- in the course there were 16 issues specifically dealing with our plant. 17 Q: With your plant. But they were -- and of 18 course they were course -- they -- they were issues which 19 only you were asked to address? 20 A: I'm not sure I understand -- 21 Q: Okay, I'm sorry. The -- the format of 22 the course, the way it's -- the way it's put together, I put 23 that very badly, I'm sorry, the way -- the way the course is 24 put together is so that you, a particular operator, gain the 25 opportunity to -- to -- to learn things about the particular

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1 plant that you're working in. Is that correct? 2 A: That'd be correct. 3 Q: Okay. So how -- how does that occur? Do 4 the people putting together the course know your plant or is 5 it from information that you give to the people giving the 6 course? 7 A: Each individual lesson will -- will ask 8 you for specifics about your course such as drying perhaps, 9 the solids contact chamber, being able to determine what the 10 volumes would be, what the flow rates would be, as it applies 11 to your plant. 12 Q: And it is a fairly comprehensive course 13 then in terms of allowing you to go through most of the 14 principle processes in the plant where you work? 15 A: I wouldn't say that it would be 16 comprehensive. I would say it'd be basic. 17 Q: It's basic. But it does go beyond the 18 level of your, you know, your initial education? It -- it's 19 just a little bit more specific? 20 A: Yes. 21 Q: Okay. And the -- the -- the sewage -- 22 the waste water course, that was just a two (2) day course? 23 A: That's correct. 24 Q: Was that -- did that have plant specific 25 elements in it too?

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1 A: Yes, it did. 2 Q: Okay. So that once again, you were -- 3 you were allowed to -- to -- to explore aspects of the sewage 4 treatment plant that exists here in North Battleford as part 5 of that course? 6 A: Yes. The course basically presented a 7 generic plant and dealt with each of the processes in that 8 plant. 9 Q: But then were you allowed to -- did you 10 raise particular concerns or problems or issues or something 11 about the special configuration of the North Battleford 12 plant, as a way of comparing it with that generic model? Did 13 it go into that kind of detail? 14 A: No, I don't believe it did. 15 Q: Okay. So it stuck fairly close to the 16 generic treatment process? 17 A: Yes. 18 Q: Okay. I understand that you then 19 subsequently gained your -- your level -- your Class 3 level 20 designation some time in July of 2000. Is that correct? 21 A: That's correct. 22 Q: And I believe if you look at tab 3 in 23 your binder there is notification there from Mr. Gus 24 Feitzelmayer that you have, in fact, gained that designation. 25 Do you remember receiving that confirmation?

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1 A: Yes, I do. 2 Q: Now apart from the -- the -- the -- you 3 will see that this letter mentions that that confirmation is 4 a -- is based upon certain factors, certain -- certain goals 5 you've been able to achieve. What did you have to do in 6 addition to the courses you've already take -- you've 7 already -- you've already described to us, to gain that level 8 3 designation, anything else? 9 A: Yes, the certification is based on three 10 (3) criterium, one (1) will be education, the second will be 11 experience and the third will be what they refer to as 12 continuing education units. 13 Experience will mean that you must be in 14 direct responsible control of a plant for so many hours, so 15 many days, so many weeks or so many years, in order to meet 16 their -- their criteria. 17 The CUs will be such things a courses in 18 chlorine or -- or courses related to the treatment processes. 19 Q: So in terms of the basic educational 20 component to that qualification, that would have been the 21 water and waste water courses we've already talked about, the 22 fact that you had already done some basic education at Kelsey 23 and then you've done subsequent courses. That was taken into 24 account was it? 25 A: That's correct.

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1 Q: Okay. And the -- the -- the -- the 2 amount of experience and time you spent in direct control of 3 the plant, are there a set number of hours for that -- for a 4 level 3 operator? 5 A: I believe it's a combination of all three 6 (3) criterium and there -- they -- well they have a formula 7 where they give weight to each one (1). 8 Q: I see, so it -- there's not necessarily 9 a -- a fixed number of hours you have to achieve, it -- it 10 can be if you -- if you have educational -- an educational 11 component they like, the number of hours can be less for some 12 operators than for others? 13 A: That's correct. 14 Q: Okay. And the other educational units 15 that you'd taken, are we talking there about the -- the 16 confined space entry type of course, the WHMIS, the chlorine 17 workshop, the transportation of dangerous goods and the first 18 aid. That kind of course work, is that what -- is that what 19 you mean? 20 A: Those kind of courses, I'm not sure if 21 something like a confined space course would give you any CE 22 credit, but certainly things like a chlorine course will. 23 Q: Now I'm assuming that a -- a significant 24 component of those additional courses has to do with 25 occupational health and safety issues; is that correct?

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1 A: Can you ask that question again. 2 Q: The -- a significant component of those 3 additional courses I mentioned, the confined space entry, the 4 first aid, the transportation of dangerous goods, a lot of 5 that is related to occupational health and safety concerns 6 within the plants, i.e the safety of operators as opposed to 7 the safety of the water? 8 A: I'm not sure if courses such as 9 occupational health and safety level 1 or 2 would be -- would 10 give you any credits towards CEUs. 11 Q: Okay. 12 A: I -- I'm not sure of their criteria in 13 that one (1). 14 Q: But if we take for instance a confined 15 space entry course, the purpose of that course is to protect 16 an operator who may have to enter a confined space; is that 17 correct? 18 A: That's correct. 19 Q: Okay. The transportation of -- is it 20 transportation of dangerous goods? 21 A: Yes. 22 Q: Is the purpose of that course to -- to 23 help the operator protect himself or herself in transporting 24 dangerous goods? 25 A: Yes, himself and herself and others.

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1 Q: Or is -- or is there a component to that 2 course which has to do with the safety of the -- the water 3 that is being treated at the -- at the plant? 4 A: No, I would say there's no component. 5 Q: Okay. 6 7 (BRIEF PAUSE) 8 9 So in addition to those courses that I've -- 10 I've just mentioned, those additional units, have you in fact 11 taken additional course work, and when I say additional, 12 additional to the basic qualifications that you've already -- 13 you've already mentioned in your -- your water and waste 14 water treatment courses. 15 Have you taken additional course work, the 16 subject matter of which is water safety issues, rather than 17 operator safety issues? 18 A: Yes, I've attended conferences such as 19 Saskatchewan Water and Waste Water Association, where they 20 hold short courses which will discuss issues involving water 21 treatment. 22 I am also in the process of studying for exams 23 dealing directly with water and waste water. 24 Q: Okay, now some of those -- what form do 25 those -- do those seminars and workshops take, the ones which

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1 deal with water and waste water treatment, and -- and -- and 2 direct attention to safety issues, are they a regular 3 occurrence, is this something which is habitual for an 4 operator to go through or can you give us your experience in 5 that regard? 6 A: I, with my employ and with the City of 7 North Battleford, I have not taken very many formalized 8 courses. 9 Q: Okay. But you said you had taken some; 10 is that correct? 11 A: Yes. 12 Q: And what would -- what would have been 13 the subject matter of those -- of those courses? 14 A: As I've previously mentioned before, I've 15 taken such things as confined space, chlorine handling -- 16 Q: Right. 17 A: -- and mandatory courses such as first 18 aid, CPR, transportation of dangerous goods, hydrogen 19 sulphide; there's a number of courses that may directly deal 20 with the safety of the operator or possibly the water. 21 Q: Of the water as well, okay. So, as a 22 component of those, are there any -- besides those courses 23 that -- that you've just run through, are there any courses 24 that you've taken which, for instance, would help you to -- 25 to deal with possible water contamination issues?

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1 A: No, I don't believe so. 2 Q: Okay. 3 MR. COMMISSIONER: The witness indicated he's 4 presently studying to take certain exams, I'm not clear on 5 what that is about. 6 7 CONTINUED BY MR. JAMES RUSSELL: 8 Q: Mr. Hollmann, if you could enlighten us 9 on that, that would be helpful. 10 A: Yes. This opens a new issue, what -- 11 what it involves is the -- the mandatory certification of 12 operators which will be taking in effect January of year 13 2002. 14 In order to maintain my -- my level of 15 certification, I will need to write exams to that level, 16 meaning I'll need to write Class 3 Water Treatment and I'll 17 need to lead it -- I'll write a Class 3 Waste Water Treatment 18 exam in order to keep my certification. 19 MR. COMMISSIONER: Thank you. 20 21 CONTINUED BY MR. JAMES RUSSELL: 22 Q: And the -- the subject matter of that 23 particular course, have you had the opportunity to review 24 what you will be studying in order to achieve that 25 qualification yet?

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1 A: Yes, I have. 2 Q: And can you describe it for us? Is it -- 3 how does it differ from the, you know, the education you've 4 already received, where does it take you beyond what you 5 already know? 6 A: The course -- they are, again, 7 correspondence courses where you study at home-type courses. 8 They have several lessons for each water or waste water and 9 they deal with very specifics of -- of water and waste water 10 treatment. 11 Q: And would safety component -- would the 12 safety aspects of water treatment be part of that course, 13 have you noticed? 14 A: Yes. 15 Q: And what types of -- what types of issues 16 are -- are dealt with as far as that new course? 17 A: They are very extensive and very specific 18 with all issues of water and waste water. 19 Q: Contamination issues? 20 A: Yes, I believe that's part. 21 Q: Are they -- are they detailed enough to 22 deal, for instance, with particular parasites? 23 A: They may mention them. 24 Q: Do they -- do you recall if they mention 25 cryptosporidium or giardia?

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1 A: Until this point, I haven't read on 2 cryptosporidium. 3 Q: Okay. Now, I believe that, when you 4 began as a plants operator in 1995, that would have been, 5 what, approximately four (4) years after Mr. Fluney had begun 6 his employment with the city? 7 A: That would be correct. 8 Q: Five (5) years after Mr. Fluney, was 9 there any kind of training process that you went through when 10 you joined the city as a plants operator? 11 A: Yes, I believe most of my training was -- 12 was given to me by the more experienced operators on staff. 13 Q: And -- and who would they be? 14 A: They would be the operators with several 15 years experience in -- in operation of the facilities. 16 Q: Okay. Would this -- was there a set 17 number of years -- we're talking about a sort of mentor 18 program here? 19 A: That's fair. 20 Q: Okay. Were there -- was there a set 21 number of years before one was allowed to become a mentor? 22 A: No. 23 Q: Okay. So these were just people who had 24 been working at the plants for some time and knew -- knew 25 the -- knew the procedures?

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1 A: That's correct. 2 Q: Okay. So what kind of process did they 3 put you through? 4 A: If I can deal with the surface water 5 treatment plant. When I began my employment with the city, I 6 would spend time there, I'd be shown the processes and 7 general operation of the plant. 8 Q: Okay. And the same at the groundwater 9 treatment plant, I'm assuming? 10 A: Yes, at the sewage treatment plant the 11 groundwater is -- is certainly not as complex as either the 12 sewage treatment plant or -- or the surface water treatment 13 plant. 14 Q: Okay. Which was the most difficult plant 15 to come to terms with and learn? 16 A: I would say probably the sewage treatment 17 plant. 18 Q: Okay. Is there any particular reason you 19 have for saying that? 20 A: The sewage treatment plant is a very 21 labour-intensive plant. 22 Q: And why is it labour intensive? 23 A: It's a very old plant. Certain amount of 24 breakdowns of the processes that you're dealing with sewage 25 treatment plant, very complicated.

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1 Q: How does the surface water treatment 2 plant compare, or how did it compare when you were going 3 through this training process? 4 A: I would say it was fairly much on par 5 with -- with the sewage treatment plant. It -- it is also a 6 very complex plant and there are many things to know. 7 Q: That was labour intensive? Was the -- 8 A: Not as labour -- well, it can be labour 9 intensive. 10 Q: Okay. And once again, I'm assuming 11 during the peak season when turbidity levels rise and so 12 forth it can become a very difficult plant at that time? 13 A: Yes. 14 Q: You were mentored to senior operator -- 15 was there any kind of -- was there a time -- did a time 16 arrive when you went through any formal evaluation process to 17 ascertain whether you had the competence to -- to -- to be 18 left in charge of these plants? 19 A: Yes. Approximately once a week my 20 foreman at the time, Mr. Ivan Katzell would come and take 21 me -- personally take me on a tour of the plant and ask me 22 several questions about the operation of the plants and -- 23 Q: And you feel at that time that Mr. 24 Katzell was -- was testing your knowledge and your ability in 25 relation to those plants?

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1 A: Yes. 2 Q: Okay. And can you tell us what he would 3 test you on? 4 A: Yes, he would tour me of the plant, like 5 I said, and ask me how things operate, if things went wrong 6 how would I identify things if they did go wrong, what would 7 I do to correct these problems. 8 And he'd ask me questions about pumps and 9 chemicals, just general overall operation of the plant and -- 10 and how things worked. 11 Q: So you believe he was satisfying himself 12 to ensure that, in fact, you did have the competence to be 13 left in charge of those plants? 14 A: Yes. 15 Q: How long -- 16 MR. COMMISSIONER: I'm not clear if this 17 witness is working on his own in the plant at this point, 18 prior to the questioning, bearing in mind earlier evidence we 19 might have heard on these points, so -- 20 MR. JAMES RUSSELL: That's my next question, 21 Mr. Commissioner. 22 MR. COMMISSIONER: All right. 23 24 CONTINUED BY MR. JAMES RUSSELL: 25 Q: Can you tell us how long it was, Mr.

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1 Hollmann, before you were actually left in charge of the 2 plant, on your own? 3 A: I can't remember exactly how many months 4 it would have been or -- the priority -- you ha -- the 5 priority had to be set in order for an operator to get 6 trained as quickly as possible at Water Plant number 2 or at 7 the Holliday Plant, in preparation for the busy summer season 8 when an operator would be most valuable at the time. 9 So for myself, I was trained in the spring 10 time and I was ready by the summer time to operate that plant 11 by myself. 12 Q: And for most of the early time, I'm 13 assuming you would have been working in conjunction with 14 other people? 15 A: Yes. 16 Q: But then it would come a time when, 17 perhaps for -- for particular jobs, you could be left alone 18 to do those things on your own? 19 A: Not usually, no. 20 Q: So when you found yourself on your own, 21 were you suddenly working a shift, in charge of the -- in 22 charge of a plant by yourself? 23 A: Yes. 24 Q: And you say you can't remember 25 specifically how long that took. I'm assuming there wouldn't

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1 be a fixed period of time if Mr. Katzell were -- were testing 2 you. Would that perhaps depend upon the individual 3 operator's capabilities and the speed at which they learned? 4 Was that your observation? 5 A: I'd say that'd be fair, yes. 6 Q: Okay. But when you found yourself in 7 charge of a plant, I mean, how did you then interact with the 8 other operators, the people who'd been your mentors or with 9 Mr. Katzell? Presumably you didn't just neglect them and 10 leave them behind, did you? 11 A: No. 12 Q: No. They were there for you to call 13 upon? 14 A: Yes. 15 Q: So you -- you had access to assistance 16 and advice as when you needed it? 17 A: At all times. 18 Q: Thank you. So if you look back at the 19 training process you went through and your -- your 20 educational process, do you believe it was -- it was adequate 21 in that it fitted you to become an operator of those plants 22 in North Battleford? 23 A: Yes, I do. 24 Q: How did you -- how did you acquire a 25 knowledge of the various measurements and standards

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1 applicable to water and waste water treatment? 2 A: Well -- 3 Q: I'm referring here to -- to be fair to 4 you, I'm referring here to, you know, such things as 5 turbidity levels, chlorine levels, chemical dosages and so 6 forth? 7 A: Through the surface water treatment 8 course you -- you develop that knowledge. There are also -- 9 there's constantly publications coming to the plant such as 10 the Pipeline, that's been referred to already. And other 11 environmental engineering magazines and there's -- there's 12 literature available. 13 Q: So did you, yourself, formally study 14 the -- the provincial regulations on these matters, or was 15 this just information you acquired one (1) way or another 16 from secondary sources? 17 A: No, there is -- there is a posting of 18 guidelines that I know for sure at the groundwater plants, 19 there is a posting there so you can use it for reference. 20 Q: And that posting has always been there 21 has it, in your time? 22 A: In my time it has. 23 Q: Okay. And what's contained on that 24 posting? 25 A: It's -- it's a listing of the Provincial

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1 Guidelines, the parameters. 2 Q: And which particular -- which particular 3 parameters does it actually list, does it give you an 4 exhaustive list, or are there only a few? 5 A: No, it's an exhaustive list. 6 Q: Okay. So is it your understanding that 7 that list covers the whole area covered by the Provincial 8 Guidelines in relation to water and waste water treatment? 9 A: It would certainly cover the guidelines 10 for those parameters I'm able to test. 11 Q: At the surface water plant? 12 A: Yes. 13 Q: Are there other similar guidelines 14 available to you at the sewage plant and at the groundwater 15 plant? 16 A: At the groundwater plant there is, at the 17 sewage treatment plant, no, there isn't. 18 Q: And when I'm saying -- when I'm using the 19 word is here, I'm referring to the period prior to by the 20 way, March of 2001. There may well have been changes since 21 then, so if that is not the case, if you would -- if you 22 would indicate where there's been a change, I would -- I 23 would appreciate that. 24 You -- your comments so far have been in 25 relation to the period before March of 2001?

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1 A: That's correct. 2 Q: Thank you. Since you became an operator 3 at the plants in 1995, what have you observed about the way 4 the new operators are trained who've arrived after you? 5 A: I believe up until approximately a year 6 and a half ago the operators were trained similarly to the 7 way I was trained. 8 Q: You say a year and a half ago, did 9 something occur a year and a half ago to -- to change that? 10 A: I would say -- well as we all know we 11 didn't have a foreman as of about November or so, there was 12 no formalized training for the last two (2) operators that 13 we've -- we've hired. 14 Q: Now you're referring to Mr. Katzell's 15 retirement? 16 A: Yes. 17 Q: It was my understanding that he retired 18 in December of 2000? 19 A: I believe that's correct. 20 Q: Now you say you haven't -- correct me if 21 I'm wrong, but I thought I just heard you say you hadn't had 22 a foreman since November of 2000? 23 A: That's right. 24 Q: Is there any explanation as to why his 25 retirement would be in December, but you've been without a

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1 foreman since November? 2 A: I believe he had holidays in November, 3 remaining holidays. 4 Q: Oh I see, so although he formally retired 5 in December, he was -- he was absent for some of that time 6 leading up to his retirement? 7 A: I believe that's correct. 8 Q: I see. 9 10 11 (BRIEF PAUSE) 12 13 Q: And what affect did -- what affect did 14 that have upon the way new people were being trained? 15 A: I believe it had a large affect. 16 Q: Can you -- can you be more specific? Can 17 you -- first of all, how many people would have arrived and 18 been trained in an adequate way, as far as you're concerned? 19 How many operators would we be talking about here? 20 A: Two (2). 21 Q: Okay, and who would they be? 22 A: It would be Robert Borne and Don Horne. 23 Q: Okay. And Robert Borne arrived when? 24 A: I'm not sure of the exact date, I believe 25 it was November.

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1 Q: November of 2000? 2 A: Yes. 3 Q: And did Don Horne arrive before or after 4 Robert? 5 A: I believe slightly after. 6 Q: Okay, so -- 7 A: I could be wrong on that, they were hired 8 very close to the same time. 9 Q: All right, but it was sometime in 2000; 10 right? 11 A: Yes. 12 Q: Okay. So what did you observe about 13 the -- the training process that they went through? 14 A: I believe their training process was very 15 limited. I would believe it would depend on the operator 16 they were working with at that time. 17 Q: But in your own case, I believe you said 18 you had been mentored yourself to senior operators; is that 19 correct? 20 A: That's correct. 21 Q: But there were still senior operators 22 there at that time, is that not true? 23 A: That's true. 24 Q: So was there anything to prevent these -- 25 the rookies from being mentored by the more senior people?

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1 A: In my own case I would do the best I 2 could to give any assistance to operators that they needed, 3 and I would do my best to be a mentor to them. 4 Q: Well is it in the case of these two (2) 5 new people that the -- the senior operators for some reason 6 didn't take them through the usual process that had occurred 7 in the past? 8 A: I believe that was the case at times. 9 Q: Was there any reason for that? 10 A: I don't know the reason. 11 Q: Okay. Then how did those people -- they 12 began I'm assuming, as assistant operators; is that correct? 13 A: Yes. 14 Q: Okay, then how did they become full time 15 operators? 16 A: As far as I know they are still assistant 17 operators. 18 Q: I see. Are both of them still working at 19 the plant? 20 A: No, they're not, only one (1) is, Don 21 Horne is; Robert Borne quit a while back. 22 Q: So was your concern with Mr. Horne's 23 training that Mr. -- Mr. Katzell was not there because of 24 his -- he was going through the retirement process, he was 25 not there to do the -- the kind of formal evaluation that

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1 needed to be done and had been done in your case? 2 A: That's correct. 3 Q: I see. 4 MR. COMMISSIONER: Perhaps, to the extent 5 that two (2) assistant operators were there from 6 approximately November of 2000 and you say they were still 7 assistant operators until one (1) person left and the other 8 one (1) is still there; as assistant operators, did they end 9 up as the only person in charge of the surface water plant at 10 any point in time or are they always working with someone 11 else? 12 THE WITNESS: No, they have been in direct 13 responsible control of the plants by themselves. 14 MR. COMMISSIONER: As an assistant operator? 15 THE WITNESS: They're an assistant operator, 16 yet they are running the plant by themselves. 17 18 CONTINUED BY MR. JAMES RUSSELL: 19 Q: Do you recall how quickly it was after 20 they both started that they were given that responsibility? 21 A: I'm not sure, I believe it was in a 22 couple of months. 23 Q: And so it would probably have still been 24 in -- in 2000 when they were given that responsibility? 25 A: Probably into the new year.

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1 Q: I see. 2 3 (BRIEF PAUSE) 4 5 Mr. Hollmann, as a plants operator in North 6 Battleford, how do you stay up-to-date with what's going on 7 in the water and waste water treatment business? 8 A: There are periodic articles and there are 9 papers such as the Pipeline. It is a personal interest of 10 mine, as well as a job to be -- be involved in water 11 treatment so I take it upon myself to read articles and 12 environmental magazines and such. 13 Q: So you yourself receive a copy of the 14 Pipeline when it's published? 15 A: I did. 16 Q: You did; you no longer do that? 17 A: No. 18 Q: Okay. When did you stop taking copy of 19 the Pipeline? 20 A: I believe since my membership with 21 Saskatchewan Water and Waste Water Association ran out. 22 Q: When would that be? 23 A: I'm not sure of the date. 24 Q: I see. Would it -- would be this year or 25 the previous year?

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1 A: The previous year. 2 Q: I see. And sometime in 2000 perhaps? 3 A: Yes. 4 Q: Did you deliberately allow it to run out? 5 A: Yes. 6 Q: Did you believe you were getting nothing 7 out of that membership? 8 A: Yes. 9 Q: Was the Pipeline and what was contained 10 in the Pipeline part of your complaint? 11 A: I believe it was very limited in -- in 12 the knowledge that it presented. 13 Q: Okay. So you felt it wasn't teaching you 14 anything useful? 15 A: Not all the time. 16 Q: Okay. Were there other -- were there 17 other publications you turned to because you thought you 18 can -- could get better information? 19 A: We received at -- at the Sewage Treatment 20 Plant as part of that plant, we received Environmental 21 Science magazines. 22 Q: So they were -- they are quite -- they're 23 quite scientific in nature then? 24 A: They can be. 25 Q: Are they -- so, in your case, is this a

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1 matter of personal taste because, as you say, you take a -- 2 you take an avid interest in these matters. You do have some 3 scientific training in your background. Do you believe that 4 you're different from the other operators in this regard in 5 the amount of detail you need, perhaps? 6 A: No. 7 Q: You -- do they take the same interest in 8 the science magazines you read? 9 A: I'm -- I'm not sure if they do or don't. 10 Q: Oh, I see, okay. Now, the knowledge you 11 obtained in this regard, I mean, what kind of the -- amongst 12 the operators down there, what kind of environment is there, 13 I mean, do you -- do you exchange information -- 14 A: Now -- 15 Q: -- do you discuss matters that you learn? 16 A: Yes, certainly. 17 Q: You do? Can you -- can you give us some 18 examples of -- of how that occurs and what you've learned and 19 how it's shared? 20 A: If we have a problem with any of the 21 operations or any of the equipment, we share our knowledge 22 amongst each other. It's important to understand that one 23 (1) operator will be better in one (1) thing than another 24 operator and each has their own particular skills and 25 abilities and you need to draw upon that.

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1 Q: Okay. So, for instance, in picking up 2 new knowledge, if -- if you were to gain knowledge of some 3 particular safety issue in water treatment, you would go and 4 share it with the other operators? 5 A: Yes. 6 Q: Okay. And that has occurred in the past? 7 A: Sure. 8 Q: Okay. And do they reciprocate, do they 9 share with you? 10 A: Sure. 11 12 (BRIEF PAUSE) 13 14 Q: Besides publications, I think you've 15 mentioned a couple of workshops you've taken; are there 16 any -- are there any workshops in recent history you've -- 17 you may have taken on water safety issues? 18 A: No. 19 Q: Okay. Any courses? 20 A: Not recently. 21 Q: Okay. 22 MR. COMMISSIONER: I'm not sure what recent 23 history is, so perhaps you could take it in the last year or 24 two (2) years, three (3) years, whatever the case may be? 25

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1 CONTINUED BY MR. JAMES RUSSELL: 2 Q: The last two (2) years, Mr. Hollmann? 3 A: No, I don't believe in the last two (2) 4 years. 5 Q: Are you a member of any associations that 6 deal with water and waste water? 7 A: Do I deal with any associations? 8 Q: Are you a member of them? 9 A: Not presently. 10 Q: You -- because you gave up your 11 membership in the -- the Saskatchewan Water and Waste Water 12 Association? 13 A: That's correct. 14 Q: Okay. Do you ever contact operators or 15 personnel who operate other plants in the province? 16 A: Only if I was to be at perhaps a 17 Saskatchewan Water and Waste Water Association conference or 18 perhaps one (1) of the courses I went to, we'll discuss 19 operations of our plants. 20 Q: I see. And has there been a -- has there 21 been a conference in the last two (2) years that you've 22 attended? 23 A: Not that I've attended. 24 Q: Okay. So it's not something, unless you 25 would find yourself at a conference with that person, there's

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1 no -- there's no informal exchange of information between 2 people who work in the various centres and treatment 3 processing facilities in Saskatchewan, that you have any 4 knowledge of? 5 A: That'd be correct. 6 Q: Okay. As a member of the Plants 7 Department and in pursuing and staying in -- on -- in touch 8 with new issues in water treatment, do you feel you're 9 encouraged to do that by your employer? 10 A: No, I don't. 11 Q: Do you feel you're discouraged from doing 12 it by your employer? 13 A: No, I don't feel I'm either discouraged 14 or encouraged. 15 Q: So it's a fairly neutral attitude towards 16 whether you do it or not? 17 A: Yes. 18 Q: Have you ever asked, for instance, to 19 attend a conference, a course that would further your 20 education and been denied the opportunity to do so? 21 A: Yes. 22 Q: Can you tell us when that occurred? 23 A: Certainly I've -- I've asked to attend an 24 H2S course -- a proper H2S course. The course I have right 25 now is an H2S alert course which is a small course. I didn't

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1 feel it was adequate. I wanted to attend a full course which 2 would -- would be more comprehensive than the course I took. 3 I was denied that. I've asked to go to 4 conferences or seminars. I've been denied that. 5 Q: What kinds of conferences and seminars 6 did you wish to attend? 7 A: I wished to attend the Saskatchewan Water 8 and Waste Water Association -- it's a yearly conference. 9 Q: Is that one (1) of the reasons why you -- 10 you left that association, because you weren't allowed to 11 attend the conferences? 12 A: Possibly. 13 Q: Were you given any explanation as to why 14 you -- why you were not being allowed to attend? 15 A: No. 16 Q: Did you ask for one (1)? 17 A: I don't believe I did. 18 Q: So have you raised that issue in any way 19 with your employer in a general -- a general way as to why 20 you -- you're not allowed to pursue the educational aspect of 21 your job? 22 A: I believe I have -- have brought that 23 issue up before. 24 Q: In what context? 25 A: In my discussions with my supervisors.

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1 Q: And -- and who would they be? 2 A: Randy Strelioff, specifically. 3 Q: So you -- you have discussed educational 4 matters with Mr. Strelioff? 5 A: Yes. 6 Q: Okay. Can you tell us when you did that? 7 A: I can't give you a specific date, no. 8 Q: Is it in this year or in the previous 9 year? Are we talking -- 10 A: I've discussed previously -- particularly 11 now with the mandatory certification coming in I've -- I've 12 had discussions with him about how we'd be allowed to study, 13 when we'd be allowed to write the exams. Things like that. 14 Q: So has your discussion then with Mr. 15 Strelioff been purely in relation to the new certification 16 process that's coming in? 17 A: No, we've discussed other issues such as 18 going to seminars, conferences, short courses, those type of 19 things. 20 Q: And what has been his response in that 21 regard? 22 A: I believe it's -- it's a difficult 23 position when you're in the water treatment business to send 24 people on courses because the men must do the work. So at 25 times it is difficult to send people when these courses are

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1 being held and I believe that was one (1) of his concerns. 2 Q: And was that the only concern he raised? 3 A: I believe so. 4 Q: In other words, if you were away at a 5 course who would be running the plant? 6 A: That'd be right. 7 Q: And is that because perhaps from your 8 point of view, the -- the -- the plants are short staffed? 9 A: I believe the plants are short staffed. 10 Q: And does that affect them in any other 11 way than the one (1) you just mentioned, i.e. that people are 12 in -- or in -- in your own case at least you -- you feel 13 you've been denied the right to seek additional education. 14 Does that short staffing have any other 15 affect? 16 A: Oh certainly, short staffing has many 17 affects. 18 Q: Could you -- could you list some of them 19 for us please? 20 A: Oh certainly. When you're short staffed 21 you do -- you don't have the ability to do all the work 22 that -- that may need be doing at the times, it may result in 23 a considerable amount of overtime, it may result in employees 24 who wish to take holidays off in the summertime with their 25 families, they'll be denied that, because that is our busy

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1 season and they'll be denied the right to have holidays 2 during then. 3 There's many issues. 4 Q: So generally speaking, you feel it makes 5 your job more difficult to do, do you? 6 A: Yes. 7 Q: Does that short staffing, in your view, 8 has it ever -- has it ever had an impact upon safety issues 9 at the plants in any way? 10 11 12 (BRIEF PAUSE) 13 14 A: I would say if I feel probably a little 15 bit uncomfortable that not all the staff, particularly right 16 now, would be trained and certified to the level of doing 17 operations. So, to have more people isn't always better, but 18 to have qualified and certified people would be better. 19 Q: Okay, are you saying it -- it potentially 20 could give rise to a difficulty, but in your experience in 21 the past, has it ever given rise to a safety difficulty 22 because of short staffing? 23 A: Not that I can recall. 24 Q: Okay. 25 A: No, that's -- that would be hard to say,

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1 that's -- that's -- that's a very broad question I suppose. 2 You could say if somebody was to be working many, many hours 3 he'll be fatigued, perhaps he can't do the job up to his 4 maximum abilities, that -- that can be a possible problem. 5 Q: All right, I can see that there might be 6 some potential there, but I was wondering if there'd been any 7 incidents in the past which had resulted from someone being 8 fatigued as you say, whether that had given rise to a concern 9 in your mind over water safety? 10 A: No, not that I can recall. 11 Q: Okay. Now while you've been an operator 12 in North Battleford, until as you've mentioned already, his 13 retirement towards the end of the -- the year 2000, I 14 understand that Mr. Ivan Katzell was the plant's foreman; is 15 that correct? For the whole time you've been there? 16 A: That's correct. 17 Q: Yes. I also understand that after Mr. 18 Katzell's retirement, there's been no effective plant's 19 foreman there until sometime this summer. My -- my own 20 information is possibly sometime in August of this year a new 21 foreman was appointed; is that correct? 22 A: That's correct. 23 Q: And I understand in the -- in the 24 interim, there have been one (1) or two (2) people who may 25 have -- have had some relationship with the plant, Mr. Houk

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1 and Mr. Cote, but that they weren't in fact providing any 2 kind of technical advice or -- or back up or support to the 3 people working down at the plants; is that correct? 4 A: That's correct. 5 Q: And that -- and what role has Mr. 6 Strelioff played during that time? 7 A: Mr. Strelioff would be not a technical 8 advisor to us, however, he would be more a manager, perhaps 9 decisions of when people can take leave, perhaps purchasing 10 of -- of orders and perhaps making some decisions other than 11 technical decisions. 12 Q: So has he assisted you, for instance, in 13 organizing work schedules, holiday schedules? 14 A: Yes, he has. 15 Q: Okay. As you say, ordering -- ordering 16 new parts perhaps? 17 A: Yes. 18 Q: Ordering chemicals? 19 A: Yes. 20 Q: So he can do things like that, but he 21 hasn't been a source of technical knowledge you can fall back 22 on, would that be fair to say? 23 A: Yes, it would be. 24 Q: Now I understand that sometime following 25 Mr. Katzell's retirement in 2000 and the appointment of a new

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1 plants foreman, I believe in August of 2001, you did have the 2 technical resources of Mr. MacDonald available to you as an 3 operator, did you not? 4 A: Yes. 5 Q: And when did Mr. MacDonald appear on the 6 scene? 7 A: I believe it was April. 8 Q: Some time in April. So, from that time 9 onwards, what kind of role has Mr. McDonald played in 10 relation to you as an operator and the other operators in 11 assisting you or supervising you in the running of those 12 plants? 13 A: I wouldn't say Mr. McDonald has 14 supervised us in -- in operation of the plants. Mr. 15 McDonald's role, I believe, is a consultant and we will be 16 able to ask technical information from him. I believe his 17 role is there to make improvements to the -- to the systems 18 of -- of North Battleford. 19 Q: But I assume that in the process he's 20 been a technical resource for the plant's operators, in other 21 words, the -- the gap we talked about in relation to Mr. 22 Strelioff and his not providing that technical support, 23 that's been there at least since Mr. McDonald has been on -- 24 on the -- on the site; is that not true? 25 A: Yes, to a degree.

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1 Q: Okay. So it was effectively between 2 somewhere in January of 2000 and somewhere in April of 2001 3 that the sort of technical backing component to your job was 4 missing? Of someone you could call in the event -- seek 5 advice in the event that there was a technical problem; is 6 that correct? 7 A: That's correct. 8 Q: Now, while Mr. Katzell was the plant's 9 foreman, can you tell us what kind of role he played, first 10 of all, in relation to giving you that technical advice; was 11 he someone you could call upon to problem-solve, to solve 12 technical problems that arose during the course of the job? 13 A: When you were -- used the word technical, 14 that's a very vague term. 15 Q: It is and I apologize once again. I 16 suppose I'm starting in a general way to say, well, if you 17 bear in mind the kinds of issues that arise during the course 18 of your job as a plants operator and they, I suppose, could 19 be anywhere from, you know, repairing machinery to resolving 20 some kind of problem that's occurred in the treatment 21 process, I'm assuming there are a broad range of technical 22 issues you have to deal with; is that correct? 23 A: That's correct. 24 Q: And Mr. Katzell, was he of assistance in 25 that full range of matters that you would -- might have to

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1 attend to or did attend to? 2 A: Yes, I believe he was -- he was very 3 valuable in that. 4 Q: Did you feel that there were any areas 5 where he was deficient in any way? 6 A: I perhaps -- I believe he -- he might 7 have had a slight lack of comprehension of -- about some of 8 the more intricate chemical processes that occur. 9 Q: Can you give us any examples of that? 10 11 (BRIEF PAUSE) 12 13 A: Yes, I suppose, when it -- when it comes 14 to -- perhaps I'd -- I'd give you an example perhaps when 15 we're dealing with well work or -- or something like that, 16 perhaps he wouldn't have and I wouldn't expect him to have 17 perhaps the -- the understanding about how -- how some 18 processes work. 19 Q: And did that lack of understanding lead 20 to any difficulties, as far as you could observe? 21 A: Yes. 22 Q: Could you tell us what they were? 23 A: When you say difficulties, perhaps I 24 could qualify that saying potential difficulties. 25 Q: Okay.

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1 A: Particularly one (1), I believe it -- it 2 might have been mentioned already. When we took down the 3 vari drive, I don't believe he understood the importance of 4 that vari drive and the solids contact unit operating. 5 Q: This is the incident in 1999? 6 A: I believe so. 7 Q: When the vari drive was sent out for 8 repair? 9 A: Yes. 10 Q: And you were working at the plants at 11 that time? 12 A: Yes. 13 Q: What -- what led you to believe that he 14 might not understand the -- the full implications of what was 15 going on in that particular instance? 16 A: Because I believe he let the plant 17 continue to produce water while the solids contact unit was 18 not functioning, particularly the drive was not functioning. 19 Q: And, because the drive was not 20 functioning, what did you observe was happening in the solids 21 contact unit? 22 A: It would -- I don't specifically recall 23 if I was the operator there at that time, I -- I recall that 24 I had walked through that plant and I could see that the 25 solids contact unit did not appear to be -- to be doing its

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1 job properly. As in you will -- without the drive unit 2 working properly you will not have mixing within the unit. 3 Q: And what kind of problem does that 4 create? 5 A: It can create problems such as carry over 6 into the filters, reduced running time of the filters, making 7 backwash runs -- you'll have to backwash the filters more 8 often and potential things passing through the solids contact 9 unit. 10 Q: You're talking about contamination 11 issues? 12 A: Possibly, yes. 13 Q: So at that time, what was your 14 understanding of what the solids contact unit -- I guess in 15 conjunction with the filters and the processes that are 16 contained in those components, what was your understanding of 17 what they -- what they achieved in terms of the treatment of 18 that water? 19 A: The solids contact unit is a flocculation 20 and coeg -- coagulation chamber where chemicals are 21 introduced and certainly, particulate matter is dropped out 22 and removed from the water. 23 Q: It's a barrier? 24 A: Yes, it is. 25 Q: What is it a barrier to?

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1 A: It's a barrier to whatever will be in the 2 raw water. 3 Q: Is that just dirt, or could it be 4 organisms? 5 A: It can be anything. 6 Q: Live? Living -- living things? 7 A: Sure. 8 Q: Parasites? 9 A: Sure. 10 Q: You believe that the solids contact plays 11 a unit -- plays a, sorry, a role in removing parasites from 12 the water? 13 A: Yes. 14 Q: Is it the only component that plays that 15 role? 16 A: No. 17 Q: What would be the other component? 18 A: Well, there's -- when we talk about 19 barriers there's -- there would be certainly many barriers if 20 we're -- are you talking about barriers located just within 21 the plant? Or if we're just talking about barriers located 22 within the plant, when it first comes in there will be small 23 raw water intake where the water will be settled for awhile. 24 You'll have barriers of your solids contact 25 unit, you'll have barriers of your filters will be barriers.

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  1  Those are the barriers that'd be in place.
  2                 Q:   So once again, let me -- let me try and
  3  be more specific.  If we're talking about -- you've mentioned
  4  parasite removal.  Which of those barriers, is it your
  5  understanding, are -- are a part of parasite removal?
  6                 A:   I believe they all work in concert.
  7                 Q:   When you say they all, can you list the
  8  ones which you feel work together in removing parasites from
  9  the water?
 10                 A:   Well in our plant, we -- we basically
 11  have the solids contact unit and the filters.  When -- when
 12  you're talking about barriers, there -- there will be other
 13  barriers I believe other than just physical barriers. 
 14  When -- when you're talking about barriers, you're adding the
 15  addition of alum and your addition of aluminex in addition of
 16  polymer.  Is that considered a barrier?  I believe it is
 17  considered a --
 18                 Q:   Right.
 19                 A:   -- barrier.  So --
 20                 Q:   The coagulation process?
 21                 A:   Certainly.
 22                 Q:   Yes?  
 23                 A:   And that'll be a barrier in itself.  Not
 24  just saying that the solids contact unit is a barrier, I
 25  bel -- believe the addition of the chemicals is also a

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1 barrier, if you want to put it that way. I mean, we have 2 certain things that will remove sand out -- out of their sand 3 separaters. We have blow offs -- at what point do you 4 identify one (1) being a barrier where another one (1) is not 5 a barrier? 6 So it's, in my opinion, there are many 7 barriers. 8 Q: Right. So it's -- it's part of, as you 9 say, a continuous process of -- of coagulation, flocculation, 10 sedimentation, filtering out contaminants in the water? 11 A: Correct. 12 Q: Okay. And you've -- you've mentioned 13 parasite contamination. And of course, as you're aware, that 14 we're very much concerned, as part of this Inquiry, with 15 cryptosporidium contamination. 16 Which part of the -- does the solids contact 17 unit play the same role in relation to the removal of 18 cryptosporidium from the water as the -- the role you've just 19 described? Is that part of the process for removing 20 cryptosporidium? 21 A: I believe the solids contact unit can. 22 Q: Okay. Is there any -- is there anything 23 else which assists in that process, other than you've -- 24 you've mentioned, the coagulation, the flocculation, the 25 sedimentation, the general process? Is that part of the

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1 process for removing cryptosporidium as well? 2 A: Are you asking, is the solid contact unit 3 part of the process in removing cryptosporidium? 4 Q: No. Sorry, once again I'm sorry to keep 5 confusing you here. Are you -- I think you mentioned earlier 6 that you didn't see separate barriers, first of all, you saw 7 a -- a continuous process? 8 A: Yes. 9 Q: And that process, I'm assuming, would 10 be -- would be the way that cryptosporidium is removed from 11 the water by putting the water through that process; is that 12 correct? 13 A: Yes. 14 Q: Okay. And as part of that, the solids 15 contact unit plays its role; is that correct? 16 A: That's right. 17 Q: And I'm assuming the filters also play 18 their role in that? 19 A: Yes. 20 Q: Okay. And in relation to 21 cryptosporidium, what about the chlorination process? 22 A: The chlorination process what -- what I 23 have -- know now, right now, will not -- is not effective in 24 killing or removing cryptosporidium. 25 Q: Now you know that now, so let's -- let's

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1 go back to before March of 2001. What was your view then of 2 the role played by the chlorination process in relation to 3 cryptosporidium? 4 A: I believe I knew then that the 5 chlorination was ineffective in -- in killing 6 cryptosporidium. 7 Q: So that was not part of the barrier 8 process at that time, as far as you were concerned? 9 A: Not for removal of cryptosporidium, no. 10 Q: Now we were talking about the -- the vari 11 drive incident in 1999, and I believe you -- 12 MR. COMMISSIONER: You're fading away on us. 13 MR. JAMES RUSSELL: Oh, sorry, Mr. 14 Commissioner. 15 MR. COMMISSIONER: That's all right. 16 17 CONTINUED BY MR. JAMES RUSSELL: 18 Q: We were talking about the -- the 19 VariDrive incident in 1999, and I think you were expressing 20 some reservations about the way Mr. -- Mr. Katzell had 21 handled that incident; is that correct? 22 A: Yes. 23 Q: And what were your reservations at that 24 time? 25 A: My reservations were that -- that I -- I

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1 think there could have been a better way of handling the 2 situation. 3 I -- I believe that possibly before that unit 4 had been taken out, I believe that possibly a standby unit or 5 a back up unit should have been in place before the original 6 unit was removed. 7 Q: And why was that a concern to you at that 8 time? 9 A: Without a drive unit you had no proper 10 mixing of -- of the chemicals. 11 Q: So are you saying that that meant the -- 12 the barrier process was compromised? 13 A: Yes. 14 Q: And did you perceive a risk of 15 contamination at that time? 16 A: I saw it as being a possibility. 17 Q: So was that one (1) of your concerns? 18 A: Yes. 19 Q: Did you mention that concern to anyone? 20 A: I discussed it with another operator. 21 Q: Who was that other operator? 22 A: Peter Allen. 23 Q: What did you discuss with him, can you 24 tell us what you said? 25 A: Yes, I believe his concerns were similar

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1 to mine, that the barrier had been weakened. 2 Q: Were you both concerned about 3 contamination at that time? 4 A: Pardon me? 5 Q: Were you both concerned about 6 contamination at that time? 7 A: Concerned about possible contamination. 8 Q: Possible contamination at that time. 9 Were you -- were you specific in your concerns? Did you -- 10 did you think about cryptosporidium or parasite 11 contamination? 12 A: No, I didn't think about cryptosporidium 13 at that time, no. 14 Q: So it was just a general concern that 15 because a barrier was down there's a possibility of whatever 16 might be in the water might get through? 17 A: That's correct. 18 Q: Okay. Did you or did anyone else in your 19 presence raise that concern with Mr. Katzell at that time? 20 A: Not in my presence. 21 Q: Okay. 22 MR. COMMISSIONER: Is this a good time to end 23 the session here? 24 MR. JAMES RUSSELL: I think it might be, Mr. 25 Commissioner.

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1 MR. COMMISSIONER: All right. Perhaps we'll 2 finish off for today, and I take it you're available for 3 tomorrow, Mr. Hollmann? 4 THE WITNESS: Yes. 5 6 (WITNESS RETIRES) 7 8 MR. COMMISSIONER: Yes. So I guess we'll 9 resume at 9:30 tomorrow morning. 10 MR. JAMES RUSSELL: Thank you, Mr. 11 Commissioner. 12 MR. COMMISSIONER: Hmm hmm. 13 14 --- Upon adjourning at 4:50 p.m. 15 16 17 18 19 20 21 22 23 24 25