Recreational Water Health Hazards: Swimming Pools

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Recreational Water Health HazardsSwimming Pools

• Alana Sulka, MPH
• East Metro Health District
• March 2007

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Purpose of Training

• Define the problem
• How easily can illness happen?
• Educate pool operators of the risks associated
  with treated recreational water venues
• Identify and describe frequently acquired
  infections
• Identify control measures to reduce the risk of
  infection

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Recreational Water Illness

• Over the past 10 years, pool related outbreaks
  have sickened over 10,000 individuals
• In 2004 alone, CDC reported 43 waterborne disease
  outbreaks (WBDOs) at treated water venues
• 2,446 cases of illness
• Outbreaks are most likely to be associated with
• Summer months
• Treated water venues
• Gastrointestinal illness

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Health Risks Associated with Swimming

• Risk of infection present in pool/spa water
• A few germs can infect large numbers of swimmers
• Illness through many routes
• Ingestion
• Dermatologic
• Respiratory
• Wild and domestic animals and infected humans can
  be the source of germs
• Weather conditions and high temperatures can also
  cause overcrowding and decreased water quality
• Deficiencies leading to outbreaks include
  problems with water quality, venue design, usage,
  and maintenance

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Common Elements in Pool Related Outbreaks

• Presence of diaper-aged children in the water
• Diaper changing in vicinity of pool
• Overcrowding
• Improper hygiene
• Not showering before and after entering pool
• Entering water with open, weeping lesions, cuts
  or scrapes
• Inadequate pool/spa maintenance
• Inadequate chlorine residual and filtration
• Cryptosporidium is chlorine resistant!!
• Lack of awareness among pool operators concerning
  the role of chlorine and pH in preventing disease
  spread

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Common Waterborne Infections

• Gastrointestinal Illnesses
• Cryptosporidium species (Crypto)
• Escherichia coli
• Norovirus
• Shigella species
• Respiratory Illnesses
• Legionella species
• Naegleria fowleri
• Dermatologic Illnesses
• Pseudomonas aeruginosa
• Staphylococcus species

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Cryptosporidium parvum (Crypto)

• During the past two decades, Crypto has become
  recognized as one of the most common causes of
  waterborne illness in the United States
• Found in infected peoples stool and cannot be
  seen by the naked eye
• Protected by an outer shell that allows it to
  survive for long periods of time in the
  environment
• Resistant to chlorine disinfection found in
  pools  
• Can survive for days in a properly disinfected
  pool

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Crypto (cont.)

• How can Crypto be spread?
• By swallowing contaminated water
• By putting something in your mouth or
  accidentally swallowing something that has come
  in contact with the stool of a person or animal
  infected with Crypto
• By swallowing Crypto picked up from surfaces
  (such as lounge chairs, picnic tables, bathroom
  fixtures, changing tables) contaminated with
  stool from an infected person
• Common symptoms include
• Watery diarrhea, dehydration, weight loss,
  stomach cramps or pain, fever, nausea, and
  vomiting
• Symptoms generally occur 7 days after exposure
• In persons with healthy immune systems, symptoms
  usually last about 1 to 2 weeks

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Eschericia coli O157H7

• Infection can occur after swimming in or drinking
  contaminated water
• Common symptoms include
• Severe bloody diarrhea and abdominal cramps
• Fever is generally not present
• Symptoms generally occur 2 to 5 days after
  exposure
• In persons with healthy immune systems, symptoms
  usually last about 5 to 10 days
• Hemolytic Uremic Syndrome (HUS) develops in about
  5 of reported E. coli O157H7 cases, most
  frequently in young children or the elderly
• May result in kidney failure and death

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Pseudomonas aeruginosa

• Commonly referred to as Hot Tub Rash
• Skin may become itchy and progress to a bumpy red
  rash that may become tender
• There may also be pus-filled blisters that are
  usually found surrounding hair follicles
• Because a swimsuit can keep contaminated water in
  contact with the skin longer, the rash may be
  worse under a persons swimsuit
• Spread by direct skin contact with contaminated
  water
• The rash usually occurs within a few days of
  swimming in poorly maintained hot tubs or spas
• can also be spread by swimming in a contaminated
  pools
• Ensuring frequent testing, control of
  disinfectant (usually chlorine or bromine)
  levels, and pH control are likely to prevent the
  spread

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Scenarios for Infection
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Scenario 1

• Recreational water facility X with swimming
  pools, wading pools, and water slides. A 3 year
  old wader has diarrhea in her swimming diaper and
  continues to wade in the wading pool.

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What should you think about?

• Should the wading pool be shut down?
• Yes, until the pool is properly treated and
  tested
• What chlorine residual testing/shocking should be
  done?
• See Environmental Health Fecal Contamination
  Protocol
• Are waders at risk?
• YES!!!!
• Many infectious agents only take ingestion of a
  few particles to cause illness
• If two or more people became ill was Public
  Health notified?

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Scenario 2
A swimmer enters a neighborhood swimming pool.
He has had a stomach bug for the past 48 hours
and experienced vomiting and diarrhea. His last
episode of diarrhea was 3 hours before swimming.
He has no fever and feels moderately well. He
had no vomiting or diarrhea while at the pool
facilities, but upon returning home has diarrhea
again.
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What should you think about?

• Is there an infection risk?
• Yes, until the pool is properly treated and
  tested
• A wash of water over the perianal region of an
  infectious individual can contaminate a body of
  water and result in illness
• Are swimmers at risk?
• YES!!!!
• Many infectious agents only take ingestion of a
  few particles to cause illness
• If two or more people became ill was Public
  Health notified?

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Scenario 3
An adult bather enters a neighborhood hot
tub/spa. He has a slight rash with a few raised,
pimple like places on his thigh and face. One of
these pimples has ruptured and is draining a
little.
Photo source www.ronjones.org
Photo source www.ronjones.org
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What should you think about?

• Is there an infection risk?
• Yes
• Skin infections, such as MRSA, are highly
  contagious
• Staphylococcus and Pseudomonas can survive in hot
  water (i.e. hot tub water)
• Are bathers at risk?
• YES!!!!
• Infection can occur when bathers come in contact
  with the infected bather, water or contaminated
  surfaces in and around the hot tub or pool
• If two or more people became ill was Public
  Health notified?

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Outbreaks
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Georgia Waterpark X E. coli O157H7 Outbreak,
June 1998

• Daycare provider called Public Health to report
  cluster
• 26/35 cases attended Waterpark X on two separate
  dates in June
• Kiddie pool implicated as risk factor
• Infection traced to GA school lunch hamburger
  served in May 1998

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Georgia Waterpark X E. coli O157H7 Outbreak,
June 1998

• The index case never identified
• Chlorine levels overwhelmed by the organic load,
  leading to E. coli O157H7 in pool
• Other risky scenarios
  included diaper changing
  on pool deck

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Respiratory Illness Outbreak, June 2002

• Acute respiratory infection in 4 persons
  following spa use in a private residence facility
• Symptoms included
• Nausea
• Fever
• Headache
• Chills
• No infectious agent identified
• Legionella species suspected

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Cryptosporidium Outbreak, July 2002

• Three children infected
• Reported among child care center attendees
• Illnesses followed a reported fecal accident in a
  wading pool
• Records on water
  treatments for pool
  were not available

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Infection Control Measures

• No swimming with diarrhea/vomiting
• No diapered children in pool
• No diaper changing on pool decking
• No swimming with open, bleeding, or weeping
  lesions or cuts
• No animals allowed in pool or on pool decking
• No food or beverage consumption within 5 feet of
  pool
• No glass containers allowed in pool enclosure
• Shower before and after entering pool
• Wash hands after using restroom, changing diapers
  and eating

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Pool Related Illness Potential Control Measures

• Ensure adequate chlorine levels and proper
  filtration
• Test water regularly
• Computerized/electronic testing
• Ensure staff properly trained and equipped
• Pool/spa closure policy and procedures
• No-depth kiddie pools for diaper-aged children
• Provide sanitizing materials in bathrooms and
  diaper changing areas

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References

• http//www.cdc.gov/healthyswimming/
• http//www.cdc.gov/mmwr/preview/mmwrhtml/ss5512a1.
  htm
• http//www.health.state.mn.us/divs/eh/beaches/beac
  hbugs.html

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Key Regulations Reducing Risk of Disease
Transmission

• David Hornsby
• Gwinnett County Environmental Health

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5 Key Requirements

• Disinfectant Level
• pH Level
• Chemical Testing
• Glass Restriction
• Food and Beverage Restriction

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Disinfectant Level

• Free available chlorine must be maintained
  between 1.5 part-per-million (ppm) and 10 ppm.
• Free available bromine must be maintained between
  3.0 ppm and 20.0 ppm.

By adhering to these requirements, most germs
will be killed, reducing risk of disease
transmission.
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Disinfecting Level

• Stabilized chlorine must be maintained at a
  minimum level of 3.0p.p.m.

Sunlight reduces the amount of chlorine in pool
water. The addition of chemical chlorine
stabilizer (cyanuric acid) protects the chlorine
from the sun. However, stabilizer does interfere
with chlorines ability to disinfect. When
stabilizer is used, the free available chlorine
level must be at a minimum level of 3.0ppm to
compensate for this interference.
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pH Level

• pH level must be maintained between 7.2 and 7.8

• Adherence to this requirement reduces the risk of
  disease transmission. When the pH level is above
  7.8, the most effective chemical form of free
  available chlorine (hypochlorous acid) is
  significantly reduced. Also, by maintaining the
  pH between 7.2 and 7.8 skin and eye irritation
  will be minimized.

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Chemical Testing

• Chemical testing must be performed on a minimum
  DAILY basis.
• A pool test kit using the reagent,
  Diethyl-p-phenylenediamine (DPD) must be used

Chlorine/ bromine and pH levels can fluctuate.
The DPD reagent reacts with pool water to
indicate the amount of free available chlorine or
bromine. These disinfectants kill germs. The
other main pool test kit uses the reagent,
Orthotolidine (OTO) to indicate the amount of
total chlorine or bromine. Total chlorine or
bromine level does not indicate the level of
disinfection.
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Glass

• No glass is allowed in the pool enclosure

• Blood from a cut can contaminate water or
  surfaces, spreading germs.

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Food and Beverages

• No food or beverage is allowed within five feet
  of the pool

Food particles or spilled beverages, in the warm
water environment of a pool, can lead to germs
spreading in the water.
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Thank you

• Please complete the evaluation tool provided and
  return as instructed on the evaluation.
• If you are viewing this on the website, the
  evaluation is available for download along with
  the presentaion

Alana C. Sulka, MPH Epidemiologist East Metro
Health District Office [phone] ASulka_at_dhr.
state.ga.us
David HornsbyPool and Body Art Program
ManagerGwinnett County Environmental HealthEast
Metro Health District 770-963-5132,
Ext.131 DHHornsby_at_dhr.state.ga.us