Recreational Water Illnesses: A 2011 Comprehensive Overview Roy Vore, Ph.D., NSPF ® I, CPO ® Vore & Associates LLC [email protected] Michael Lowry,

Recreational Water Illnesses:A 2011 Comprehensive Overview

Roy Vore, Roy Vore, Ph.D., NSPFPh.D., NSPF®®I, CPOI, CPO®®

Vore & Associates LLCVore & Associates LLC

[email protected]@gmail.com

Michael LowryMichael Lowry, NSPF, NSPF®®I, CPOI, CPO®®

Lowry and AssociatesLowry and Associates

[email protected]@lowryassociates.ca

CIPHI Annual Educational ConferenceJune 26-29, 2011, Halifax, NS

(C) 2011 Vore & Associates(C) 2011 Vore & Associates 11

Ways to guarantee zero outbreaks Ways to guarantee zero outbreaks of infectionsof infections

1.1. Keep the pH below 2.0 or above 12.0Keep the pH below 2.0 or above 12.0

2.2. Never let anyone touch the water or Never let anyone touch the water or inhale the air above the waterinhale the air above the water

Every other treatment options means there Every other treatment options means there is a risk of an RWI outbreak. is a risk of an RWI outbreak.


Recreational water illnesses (RWIs) Recreational water illnesses (RWIs) can be transmitted in three wayscan be transmitted in three ways

Ingesting waterIngesting water Contact with waterContact with water AirAir

If you are in or near a If you are in or near a pool or hot tub that pool or hot tub that is contaminated you is contaminated you will be exposed and will be exposed and subject to infection subject to infection or illness.or illness.


How many RWIs are there?How many RWIs are there?

Nobody really knowsNobody really knows Probably less than 5% of outbreaks are ever Probably less than 5% of outbreaks are ever

recognizedrecognized Once recognized the outbreak must be reported to Once recognized the outbreak must be reported to

local department of healthlocal department of health Only outbreaks that effect 2 or more people and occur Only outbreaks that effect 2 or more people and occur

in a public facility are investigatedin a public facility are investigated Thoroughness of the investigation varies greatlyThoroughness of the investigation varies greatly The US Centers for Disease Control and Prevention The US Centers for Disease Control and Prevention

(the CDC) compiles summaries every two years(the CDC) compiles summaries every two years The summaries do not cover private homesThe summaries do not cover private homes


The US Centers of Disease Control The US Centers of Disease Control and Prevention (the “CDC”) tracks Water Borne and Prevention (the “CDC”) tracks Water Borne

Disease Outbreaks (WBDO)Disease Outbreaks (WBDO)

2005-6 major reported RWIs2005-6 major reported RWIs 78 outbreaks78 outbreaks 31 states and Guam31 states and Guam 4,412 people4,412 people 116 hospitalizations116 hospitalizations 5 death5 death

Due to under-reporting the true number is 10X to 100X higherDue to under-reporting the true number is 10X to 100X higher Minor RWIs are not reported!Minor RWIs are not reported! This number is increasing every year.This number is increasing every year. http://www.cdc.gov/mmwr/pdf/ss/ss5709.pdfhttp://www.cdc.gov/mmwr/pdf/ss/ss5709.pdf


Recreational water illnesses:Recreational water illnesses: a quick overview a quick overview

Illness typeIllness type Causative Causative agent(s)agent(s)

Frequency of Frequency of illnessillness

Press Press coveragecoverage

GastrointestinalGastrointestinal BacteriaBacteria

VirusesViruses

parasitesparasites

RareRare Very highVery high

DermalDermal PseudomonasPseudomonas Very commonVery common Very lowVery low

Disinfection by-Disinfection by-productsproducts

Very commonVery common Very lowVery low

RespiratoryRespiratory LegionellaLegionella RareRare HighHigh

Disinfection by- Disinfection by- productsproducts

Common –Common –

esp. indoorsesp. indoors

Very lowVery low


Recreational water illnesses:Recreational water illnesses:Illness v. venuesIllness v. venues

IllnessIllness PoolsPools SpasSpas

Gastro-Gastro-intestinalintestinal

E coliE coli O157:H7 O157:H7

ShigellaShigella

NorovirusNorovirus

Hepatitis AHepatitis A

CryptosporidiumCryptosporidium

GiardiaGiardia

Minimal – most users do Minimal – most users do not swallow enough water not swallow enough water for infectionfor infection

DermalDermal Ps. aeruginosaPs. aeruginosa

Chloramines (DBPs)Chloramines (DBPs)

Ps. aeruginosaPs. aeruginosa

Bromamines (DBPs)Bromamines (DBPs)

RespiratoryRespiratory

Chloramines (DBPs)Chloramines (DBPs)

(indoor pools)(indoor pools)

LegionellaLegionella

Bromamines (DBPs)Bromamines (DBPs)


Recreational water illnesses:Recreational water illnesses:Public vs. private venuesPublic vs. private venues

PoolsPools SpasSpas

Public Public facilities facilities including hotels, including hotels, condos and condos and health clubshealth clubs

GastrointestinalDermal Dermal ((Pseudomonas Pseudomonas & & DBPs)DBPs)


(DBPs @ indoor pools)(DBPs @ indoor pools)

Dermal Dermal ((Pseudomonas Pseudomonas & & DBPs)DBPs)

RespiratoryRespiratory ((LegionellaLegionella & DBPs @ & DBPs @ indoor pools)indoor pools)

Residential Residential (private homes)(private homes)



(DBPs @ indoor pools)(DBPs @ indoor pools)


RespiratoryRespiratory ((LegionellaLegionella & DBPs @ & DBPs @ indoor pools)indoor pools)


Gastrointestinal illnessGastrointestinal illness

Why only certain germs?Why only certain germs? Where do the bugs come from?Where do the bugs come from? How do you control them?How do you control them? What happens during an outbreak?What happens during an outbreak? How do you respond when something How do you respond when something

goes wrong?goes wrong?


The germs that gastrointestinal RWIs have The germs that gastrointestinal RWIs have very, very low infective dosesvery, very low infective doses

OrganismOrganism Dose that willDose that will

cause diseasecause disease

E coliE coli O157:H7 O157:H7 10 cells10 cells

NorovirusNorovirus 10 particles10 particles

GiardiaGiardia 10 –100 cysts10 –100 cysts

CryptosporidiumCryptosporidium 10 cysts10 cysts


Where do bugs that gastrointestinal Where do bugs that gastrointestinal diseases come from?diseases come from?

From swimmers!!!!From swimmers!!!! The average person swallows 1 ounce of water for every The average person swallows 1 ounce of water for every

30 minutes of swimming30 minutes of swimming Gastrointestinal illness is caused by swallowing food or Gastrointestinal illness is caused by swallowing food or

water that has contaminated with feceswater that has contaminated with feces The average person also carries 0.14 grams of feces on The average person also carries 0.14 grams of feces on

the rear end – the rear end – babies carry more!babies carry more! Add up all the bodies and you get a fair amount of fecesAdd up all the bodies and you get a fair amount of feces If a bather has an accident (formed or diarrhea) the If a bather has an accident (formed or diarrhea) the

amount of feces in the water goes way, way upamount of feces in the water goes way, way up At some point the concentration rises above the At some point the concentration rises above the

minimum for infection – and there is an outbreakminimum for infection – and there is an outbreak


US Gastrointestinal RWIs 1997-2006US Gastrointestinal RWIs 1997-2006Percent of outbreaks by pathogenPercent of outbreaks by pathogen

6.7%6.7%

8.7%

3.8%2.9%

68.3%

2.9%E coliShigellaNorovirusOtherUnidentifiedGiardiaCryptosporidium


Crypto is the only one that is chlorine resistant

Chlorine sensitive

Control of gastrointestinal illnessControl of gastrointestinal illnesscausing pathogens in poolscausing pathogens in pools

GroupGroup OrganismOrganism Killed by chlorine?Killed by chlorine?

BacteriaBacteria E coliE coli (including (including O157:H7)O157:H7)

Very quickly – all Very quickly – all bacteria killed in <1 min bacteria killed in <1 min @ 1 ppm FAC@ 1 ppm FACShigellaShigella

VirusesViruses AdenovirusAdenovirus Quickly – probably <20 Quickly – probably <20 min @ 1 ppm FACmin @ 1 ppm FACNorovirusNorovirus

ParasitesParasites GiardiaGiardia Quickly - <45 min @ 1 Quickly - <45 min @ 1 ppm FACppm FAC

CryptosporidiumCryptosporidium Killed by 20 ppm FAC Killed by 20 ppm FAC 12.75 hours in absence 12.75 hours in absence of CYAof CYA


Gastrointestinal illness: Gastrointestinal illness: Cryptosporidium Cryptosporidium is the 800 pound is the 800 pound

gorilla of RWIsgorilla of RWIs The infective unit is built like a The infective unit is built like a

basketball with two little larvae basketball with two little larvae inside the ball.inside the ball.

No combination of current No combination of current treatments will completely control treatments will completely control this germ in a timely manner.this germ in a timely manner.

Best prevention is to discourage Best prevention is to discourage swimmers who have been illswimmers who have been ill

Clinical definition of diarrhea: 3 Clinical definition of diarrhea: 3 incidents of diarrhea in a 24 hour incidents of diarrhea in a 24 hour periodperiod

People shed germs after recoveringPeople shed germs after recovering Don’t swim for at least 7 days after a Don’t swim for at least 7 days after a

clinical case of diarrheaclinical case of diarrhea


Gastrointestinal illnessGastrointestinal illnessfrom pools and spasfrom pools and spas

Many germs that cause illness (including Many germs that cause illness (including E coli, ShigellaE coli, Shigella, , Norovirus, Adenovirus, and Norovirus, Adenovirus, and GiardiaGiardia) are readily killed by ) are readily killed by 1 ppm of free chlorine1 ppm of free chlorine

The Centers for Disease Control and Prevention states The Centers for Disease Control and Prevention states that between 1993-2006 one-third of all GI illness were that between 1993-2006 one-third of all GI illness were caused by these same chlorine sensitive germs.caused by these same chlorine sensitive germs.

This means that if we are running our pools properly This means that if we are running our pools properly one-third of these serious GI illnesses would disappear one-third of these serious GI illnesses would disappear today!today!

Only one organism, Only one organism, CryptosporidiumCryptosporidium, is highly resistant , is highly resistant to chlorine – it takes 20 ppm chlorine and 12.75 hours to to chlorine – it takes 20 ppm chlorine and 12.75 hours to kill this onekill this one


Gastrointestinal illnessGastrointestinal illnessA hypothetical caseA hypothetical case

A fecal accident happens in a 75,000 gallon pool A fecal accident happens in a 75,000 gallon pool Person is infected and releases 1 billion Person is infected and releases 1 billion E. coliE. coli O157:H7 O157:H7

cells (it could also be 1 billion cells (it could also be 1 billion CryptoCrypto oocysts) oocysts) Assume all fecal matter is uniformly mixed and none is Assume all fecal matter is uniformly mixed and none is

removed by filtrationremoved by filtration Every 30 ml (1 ounce) will contain 105.8 infective units – Every 30 ml (1 ounce) will contain 105.8 infective units –

30 ml is a small swallow of water30 ml is a small swallow of water Swallowing as little as 3 ml (0.1 ounce) will cause Swallowing as little as 3 ml (0.1 ounce) will cause

diarrhea in sensitive individualsdiarrhea in sensitive individuals This amount of This amount of E coliE coli O157:H7 can be fatal to O157:H7 can be fatal to

toddlerstoddlers Imagine this in a 5000 gallon wading pool!Imagine this in a 5000 gallon wading pool!


What do you do when something What do you do when something goes wrong?goes wrong?

Base treatment on the incidentBase treatment on the incident Assume the worse case scenarioAssume the worse case scenario

What is the most difficult to kill germ that is What is the most difficult to kill germ that is likely to be present?likely to be present?

Treat for worst case Treat for worst case If you kill the difficult germs all of the sensitive If you kill the difficult germs all of the sensitive

germs will also be killed.germs will also be killed.


Health threat assessmentHealth threat assessment

AccidentAccident PathogensPathogens Most Most resistantresistant

TreatmentTreatment

PlanPlan

BloodBlood HIV, Hepatitis B, HIV, Hepatitis B, Hepatitis CHepatitis C

All similarAll similar None – pathogens not None – pathogens not spread through waterspread through water

VomitVomit E coli, E coli, Norovirus, Norovirus, Hepatitis AHepatitis A

Norovirus and Norovirus and

Hepatitis AHepatitis A

Formed Feces & Vomit Formed Feces & Vomit ResponseResponse

Formed Formed fecesfeces

E coli, GiardiaE coli, Giardia GiardiaGiardia Formed Feces & Vomit Formed Feces & Vomit ResponseResponse

DiarrheaDiarrhea E coli, Shigella, E coli, Shigella, Norovirus, Norovirus, Giardia, CryptoGiardia, Crypto

CryptoCrypto Diarrheal Accident Diarrheal Accident ResponseResponse


Formed Fecal AccidentFormed Fecal Accidentand Vomit Responseand Vomit Response

1.1. Clear and close pool at onceClear and close pool at once2.2. Scoop or net out feces – flush feces down toiletScoop or net out feces – flush feces down toilet3.3. Hold chlorine level at >2.0 ppm for 25 minutesHold chlorine level at >2.0 ppm for 25 minutes4.4. Maintain pH at 7.2-7.5 ppmMaintain pH at 7.2-7.5 ppm5.5. Filter continuouslyFilter continuously6.6. Re-open poolRe-open pool6.6. Soak net in bucket of chlorine (500 ppm FAC for 30 Soak net in bucket of chlorine (500 ppm FAC for 30

minutes)minutes)7.7. Document each vomit and fecal accident by recording Document each vomit and fecal accident by recording

date and time of the event, note whether formed stool date and time of the event, note whether formed stool or diarrhea, and note the chlorine levels at the time or or diarrhea, and note the chlorine levels at the time or observation of the event. observation of the event.

Check Check www.cdc.gov www.cdc.gov for latest informationfor latest information


Diarrheal Accident ResponseDiarrheal Accident Response

1.1. Close pool at onceClose pool at once2.2. Scoop or net out feces – flush material down toiletScoop or net out feces – flush material down toilet3.3. Raise free chlorine to 20 ppm for 12.75 hoursRaise free chlorine to 20 ppm for 12.75 hours4.4. Maintain pH at 7.2-7.5 ppmMaintain pH at 7.2-7.5 ppm5.5. Filter continuouslyFilter continuously6.6. Backwash filter to sanitary sewerBackwash filter to sanitary sewer7.7. De-chlorinate to 1 to 4 ppm free chlorineDe-chlorinate to 1 to 4 ppm free chlorine8.8. Re-open poolRe-open pool9.9. Soak net in bucket of chlorine (500 ppm FAC for 30 minutes)Soak net in bucket of chlorine (500 ppm FAC for 30 minutes)10.10. Document each vomit and fecal accident by recording date Document each vomit and fecal accident by recording date

and time of the event, note whether formed stool or diarrhea, and time of the event, note whether formed stool or diarrhea, and note the chlorine levels at the time or observation of the and note the chlorine levels at the time or observation of the event.event.

Check Check www.cdc.gov www.cdc.gov for latest informationfor latest information


The correct use of The correct use of hyperchlorination for hyperchlorination for CryptoCrypto

0

5

10

15

20

25

0 1 2 3 4 5 6 7 8 9 10 11 12 13

time in hours

pp

m o

f fr

ee c

hlo

rin

e

correct

incorrect


Keep the HOCl at 20 ppm for ENTIRE 13 hour period

Gastrointestinal illness:Gastrointestinal illness:Community response to Community response to CryptoCrypto

CryptoCrypto outbreaks are community wide outbreaks are community wide Ill bathers spread the outbreak as they migrate Ill bathers spread the outbreak as they migrate

from one pool to anotherfrom one pool to another Swim teams and reciprocal memberships in Swim teams and reciprocal memberships in

private pools are factorsprivate pools are factors Temporary closures cause ill bathers to move to Temporary closures cause ill bathers to move to

other pools – and spread the outbreakother pools – and spread the outbreak Once the outbreak is identified all pools in the Once the outbreak is identified all pools in the

regions must be hyperchlorinated at the same regions must be hyperchlorinated at the same timetime


Gastrointestinal illness:Gastrointestinal illness:recommendations from the CDCrecommendations from the CDC

Do not swim while experiencing diarrheal illness (e.g., swimming in or entering the water at pools, spas, interactive fountains, lakes, rivers, or oceans) and for 2 weeks after diarrhea or symptoms resolve if one has received a diagnosis of cryptosporidiosis or during an outbreak of cryptosporidiosis.

Take children on frequent bathroom breaks and check their diapers often.

Change diapers in the bathroom, not at the poolside. Wash children thoroughly (especially their bottoms)

with soap and water after they use the toilet or their diapers are changed and before they enter the water.

Shower before entering the water.


Dermal diseaseDermal disease

Overview of dermal disease.Overview of dermal disease. Why dermal disease?Why dermal disease? General symptoms.General symptoms. Two of dermal disease categories:Two of dermal disease categories:

Bacterial infectionsBacterial infections Chemical induced rashesChemical induced rashes

How can you tell them apart?How can you tell them apart? How do you control them?How do you control them?


Dermal disease - overviewDermal disease - overview We do not know the frequency of diseaseWe do not know the frequency of disease

Rashes are not a “reportable” diseaseRashes are not a “reportable” disease Few bathers link skin infections to pools or spasFew bathers link skin infections to pools or spas

Evidence suggests rashes are extremely commonEvidence suggests rashes are extremely common Earaches are one of the leading causes of visits to pediatricians Earaches are one of the leading causes of visits to pediatricians

during swimming seasonduring swimming season Chemical reactions may affect >5% of bathers and produce Chemical reactions may affect >5% of bathers and produce

short term rashesshort term rashes Rashes likely out-number GI disease by 100s or 1000s Rashes likely out-number GI disease by 100s or 1000s

of timesof times Most incidents cause discomfort but not serious illnessMost incidents cause discomfort but not serious illness

Many swimmers continue to swim with some minor rashesMany swimmers continue to swim with some minor rashes


Why do we see dermal disease Why do we see dermal disease with pool and spa use?with pool and spa use?

Humans are not fish – we are not designed for repeated Humans are not fish – we are not designed for repeated long immersion in waterlong immersion in water

Swimming dries out the skinSwimming dries out the skin One type of very dry skin is called “eczema”One type of very dry skin is called “eczema”

Warm water dilates the poresWarm water dilates the pores ““Stuff” in the water can enter the poresStuff” in the water can enter the pores This includes disinfection by-products and bacteriaThis includes disinfection by-products and bacteria

Repeated exposure to anything out of the ordinary may Repeated exposure to anything out of the ordinary may lead to immune system reactionslead to immune system reactions

The medical term is “contact dermatitis”The medical term is “contact dermatitis” Individual immune systems vary considerablyIndividual immune systems vary considerably

Some groups are inherently more sensitiveSome groups are inherently more sensitive Previous exposure makes some people hyper-reactivePrevious exposure makes some people hyper-reactive


Dermal disease:Dermal disease:most common complaintsmost common complaints

General skin irritation or rash that may include any of the following:General skin irritation or rash that may include any of the following: Reddened patches (erythema)Reddened patches (erythema) Particularly dry areas (xerosis)Particularly dry areas (xerosis) Itchiness (puritis)Itchiness (puritis) Weeping (pustular)Weeping (pustular) Hives (raised edematous [swollen] patches)Hives (raised edematous [swollen] patches)

Irritation can be on:Irritation can be on: Arms, legs, extremitiesArms, legs, extremities Area covered by bathing suitArea covered by bathing suit Generalized covering all body areas (less common)Generalized covering all body areas (less common)

Reactions may first be noticed:Reactions may first be noticed: Quickly after touching water (or at least in <24 hours)Quickly after touching water (or at least in <24 hours) Days after touching the water (>24 hours up to 14 days)Days after touching the water (>24 hours up to 14 days)

Reaction may be:Reaction may be: Specific to just chlorine or bromine (most common)Specific to just chlorine or bromine (most common) Generalized to all halogen treated waters (in advanced cases)Generalized to all halogen treated waters (in advanced cases)


Dermal disease: Bacterial infection byDermal disease: Bacterial infection by Pseudomonas aeruginosaPseudomonas aeruginosa

Infection: bacteria inside hair Infection: bacteria inside hair follicles resulting in immune follicles resulting in immune reaction (folliculitis)reaction (folliculitis)

Incubation: 2-14 days after Incubation: 2-14 days after exposure, rarely <24 hoursexposure, rarely <24 hours

Symptoms: Rash in armpits, Symptoms: Rash in armpits, groin, abdomen and area groin, abdomen and area cover by bathing suit. Rash cover by bathing suit. Rash may range from 2 mm red dots may range from 2 mm red dots (like a flea bite) to oozing (like a flea bite) to oozing sores (like poison ivy).sores (like poison ivy).

Average duration: 8 daysAverage duration: 8 days Treatment: usually none Treatment: usually none

required, severe cases are required, severe cases are rare but may require IV rare but may require IV antibioticsantibiotics


Typical Pseudomonas folliculitis cases

Dermal disease: Sequence of a typicalDermal disease: Sequence of a typicalPseudomonas aeruginosa Pseudomonas aeruginosa outbreakoutbreak

1.1. P aeruginosaP aeruginosa becomes established in biofilm becomes established in biofilm2.2. Sanitizer drops below critical level (bromine or Sanitizer drops below critical level (bromine or

chlorine <1 ppm) and allowschlorine <1 ppm) and allows P aeruginosa P aeruginosa to survive to survive in the waterin the water

3.3. Person stays in water >15 minutesPerson stays in water >15 minutes4.4. Warm water dilates pores in the skinWarm water dilates pores in the skin5.5. Bacteria enter the pores in the skinBacteria enter the pores in the skin6.6. Bacteria reproduce in the poresBacteria reproduce in the pores7.7. Bacteria secrete toxins that cause allergic reactionsBacteria secrete toxins that cause allergic reactions8.8. Immune system overcomes infection and toxins in Immune system overcomes infection and toxins in

about 8 daysabout 8 days


Dermal disease: Why shouldDermal disease: Why should Pseudomonas aeruginosa Pseudomonas aeruginosa worry you?worry you?

This bacterium causes more outbreaks and single This bacterium causes more outbreaks and single cases of RWI than all others combined.cases of RWI than all others combined.

Nearly all cases are minor infections.Nearly all cases are minor infections. Because the rashes are minor they are seldom Because the rashes are minor they are seldom

reported, investigated or documented by local health reported, investigated or documented by local health departmentsdepartments

Where this bacteria grows there are likely to be Where this bacteria grows there are likely to be other more serious ones also, such as other more serious ones also, such as E coliE coli O157:H7, O157:H7, ShigellaShigella and and LegionellaLegionella..

This bacteria is very easy to kill.This bacteria is very easy to kill. Rash outbreaks are an indicator of poor overall

sanitation in the facility.


Dermal disease: reactions to Dermal disease: reactions to chemicals in the waterchemicals in the water

Irritation: contact with Irritation: contact with contaminated watercontaminated water

Incubation: <24 hours, Incubation: <24 hours, sometimes in 15 minutessometimes in 15 minutes

Symptoms: Symptoms: Itchy rashItchy rash on hands, arms, legs, on hands, arms, legs, and area not covered by and area not covered by bathing suit; may get bathing suit; may get much worse if swimming much worse if swimming with a previous rashwith a previous rash

Average duration: daysAverage duration: days Treatment: none Treatment: none

required, change type of required, change type of sanitizer or stop sanitizer or stop swimming in severe swimming in severe casescases


Severe contact dermatitis – few pool/spa rashes are this bad

Dermal disease:Dermal disease:possible chemical mechanismspossible chemical mechanisms

Water dehydrates skin and removes protective oilsWater dehydrates skin and removes protective oils Disinfection by-products (chloramines and Disinfection by-products (chloramines and

bromamines) enter the skinbromamines) enter the skin Repeated exposure (many, many events) leads to Repeated exposure (many, many events) leads to

low level irritationlow level irritation Continued exposure leads to progressively stronger Continued exposure leads to progressively stronger

immune reactionsimmune reactions With increasing age the skin becomes less oily and With increasing age the skin becomes less oily and

this helps aggravate the reactionthis helps aggravate the reaction With continued exposure some become cross-With continued exposure some become cross-

reactive to all halogens and unable to enter waterreactive to all halogens and unable to enter water


Quick rash comparisonQuick rash comparisonChemical reactionChemical reaction Bacterial infectionBacterial infection

Time to first Time to first symptomssymptoms

<24 hours, can be <24 hours, can be <10 minutes<10 minutes

>24 hours, often >2 >24 hours, often >2 days up to 14 daysdays up to 14 days

Duration of Duration of symptomssymptoms

Days to weeksDays to weeks <14 days, usually 8 <14 days, usually 8 daysdays

Typical Typical appearanceappearance

Red Red itchyitchy rash rash Red rash (like bug Red rash (like bug bites)bites)

Reaction on Reaction on re-exposurere-exposure

Progressively worseProgressively worse No changeNo change

Medical Medical treatmenttreatment

Not usually requiredNot usually required Not usually requiredNot usually required


Time between swimming and rash is the key to determining the cause

Preventing dermal diseasePreventing dermal disease Maintain chlorine or bromine Maintain chlorine or bromine at all timesat all times

PseudomonasPseudomonas and and LegionellaLegionella thrive in under-treated thrive in under-treated facilities – and that is not a good thingfacilities – and that is not a good thing

In pools keep combined chlorine to In pools keep combined chlorine to <<0.2 ppm0.2 ppm Routinely use a non-halogen oxidizing treatment Routinely use a non-halogen oxidizing treatment

(monopersulfate, ozone, or UV) instead of (monopersulfate, ozone, or UV) instead of superchlorination. superchlorination.

Stop breakpoint treatments that are used to reduce Stop breakpoint treatments that are used to reduce persistent combined chlorine.persistent combined chlorine.

Replace water if oxidation does not workReplace water if oxidation does not work Treat spas after every use period to oxidize

organics and convert bromide to bromine Oxidize with potassium monopersulfate or chlorineOxidize with potassium monopersulfate or chlorine


Respiratory diseaseRespiratory disease

Overview of respiratory diseaseOverview of respiratory disease Why respiratory disease?Why respiratory disease? Two categories:Two categories:

Bacterial infectionsBacterial infections Chemical induced reactionsChemical induced reactions

Where are they likely to happen?Where are they likely to happen? How do you control them?How do you control them?


Respiratory disease:Respiratory disease:Legionella pneumophila Legionella pneumophila

Grows in biofilmsGrows in biofilms Thrives at 90Thrives at 90OOF to 106F to 106OOF and F and

neutral pHneutral pH Almost all infections from hot Almost all infections from hot

tubs.tubs. WHO: 50+ outbreaks on WHO: 50+ outbreaks on

cruise shipscruise ships Not resistant to chlorineNot resistant to chlorine Infection: inhaled contaminated Infection: inhaled contaminated

droplets, dose size unknowndroplets, dose size unknown Treatment: antibiotics Treatment: antibiotics

(Legionnaire’s Disease)(Legionnaire’s Disease) Vacation and rental properties

are high risk


There are documented cases where individuals became infected simply by walking past a contaminated hot tub with the blowers on.

Respiratory diseaseRespiratory disease: sequence of a : sequence of a typical typical Legionella spa outbreakLegionella spa outbreak

1.1. Legionella pneumophila Legionella pneumophila becomes established in biofilmbecomes established in biofilm2.2. Bacteria break free of the biofilm Bacteria break free of the biofilm 3.3. Chlorine level <1 ppm allowsChlorine level <1 ppm allows Legionella pneumophila Legionella pneumophila to to

survive in the watersurvive in the water4.4. Bubbles trap Bubbles trap Legionella pneumophila Legionella pneumophila 5.5. Air bubbles break the surface and burstAir bubbles break the surface and burst6.6. Fine droplets float in the breathing zoneFine droplets float in the breathing zone7.7. Droplets are inhaled into the lungsDroplets are inhaled into the lungs8.8. Bacteria enter White Blood Cells in the lungsBacteria enter White Blood Cells in the lungs9.9. Bacteria reproduce inside the White Blood Cells Bacteria reproduce inside the White Blood Cells 10.10. Outcome either Legionnaire’s Disease or Pontiac FeverOutcome either Legionnaire’s Disease or Pontiac Fever


Legionellosis is not spread by person-to-person contactLegionellosis is not spread by person-to-person contact

Respiratory disease: Respiratory disease: Two forms of LegionellosisTwo forms of Legionellosis

Legionnaire’s Disease: severe formLegionnaire’s Disease: severe form Pneumonia plus fever, chills, coughPneumonia plus fever, chills, cough 5-15% of cases result in fatality5-15% of cases result in fatality Highest death rate in nosocomial cases and among Highest death rate in nosocomial cases and among

smokers (major risk factor)smokers (major risk factor) Pontiac fever: less severe symptomsPontiac fever: less severe symptoms

Acute onset (36 hr.), flu-like, non-pneumonicAcute onset (36 hr.), flu-like, non-pneumonic Self-limiting disease, seldom diagnosedSelf-limiting disease, seldom diagnosed Recovery in 2-5 days without treatmentRecovery in 2-5 days without treatment Most cases (perhaps >90%) of Most cases (perhaps >90%) of LegionellaLegionella

infections are Pontiac Feverinfections are Pontiac Fever


Respiratory disease: short and long Respiratory disease: short and long term chemical effectsterm chemical effects

Short term effects are well recognizedShort term effects are well recognized Pool/spa smells due to combined chlorine or brominePool/spa smells due to combined chlorine or bromine Patrons complaints indicate need for immediate Patrons complaints indicate need for immediate

actionaction Health threat not high – unless sensitive patrons are Health threat not high – unless sensitive patrons are

present, and you cannot predict thispresent, and you cannot predict this Long term affects are emergingLong term affects are emerging

Studies from Belgium have linked high indoor pool Studies from Belgium have linked high indoor pool usage to asthma usage to asthma indicatorsindicators in school children in school children

Studies are on-goingStudies are on-going Implications for casual pool users or spa users are not Implications for casual pool users or spa users are not

knownknown


Respiratory disease:Respiratory disease:Where chemicals cause diseaseWhere chemicals cause disease

Indoor pools due toIndoor pools due to Out-gassing of compounds in the waterOut-gassing of compounds in the water Poor general ventilationPoor general ventilation Over-application of chlorine for break-point treatmentOver-application of chlorine for break-point treatment

Spas of all types, especially ifSpas of all types, especially if Sanitizer is not maintained (Legionellosis)Sanitizer is not maintained (Legionellosis) pH drops to <5.5 and chlorine or bromine gas is pH drops to <5.5 and chlorine or bromine gas is

formedformed Indoors and poorly ventilatedIndoors and poorly ventilated Over-application of chlorine for break-point treatment Over-application of chlorine for break-point treatment

(probably fairly rare)(probably fairly rare)


Respiratory disease:Respiratory disease:Must do’s and four optionsMust do’s and four options

Maintain chlorine or bromine Maintain chlorine or bromine at all timesat all times to control to control bacteria (especially true for bacteria (especially true for Legionella)Legionella)

Maintain proper water managementMaintain proper water management Balance water to avoid forming chlorine or bromine gasBalance water to avoid forming chlorine or bromine gas Use appropriate oxidation to control disinfection by-productsUse appropriate oxidation to control disinfection by-products Don’t use breakpoint treatments on persistent chloraminesDon’t use breakpoint treatments on persistent chloramines

Consider these optionsConsider these options Replace superchlorination with monopersulfate, ozone, or UVReplace superchlorination with monopersulfate, ozone, or UV Use water replacement to dilute organicsUse water replacement to dilute organics Use adequate and optimized ventilation – don’t shut down the Use adequate and optimized ventilation – don’t shut down the

system at night or you defeat the entire gas exchange processsystem at night or you defeat the entire gas exchange process Require all patrons to shower and reduce organic load Require all patrons to shower and reduce organic load


RWI SummaryRWI Summary Gastrointestinal illness comes from bathersGastrointestinal illness comes from bathers

Maintaining 1 ppm FAC stops 1/3 of illnessesMaintaining 1 ppm FAC stops 1/3 of illnesses Keep bathers who had diarrhea out of the pool for >7 daysKeep bathers who had diarrhea out of the pool for >7 days

Dermal disease is from operator errorsDermal disease is from operator errors 1 ppm FAC or 2 ppm Bromine kills 1 ppm FAC or 2 ppm Bromine kills PseudomonasPseudomonas High chloramines or bromamines leads to rashesHigh chloramines or bromamines leads to rashes

Respiratory disease is from operator error or poor Respiratory disease is from operator error or poor facility designfacility design 1 ppm FAC or 2 ppm Bromine kills 1 ppm FAC or 2 ppm Bromine kills LegionellaLegionella Use oxidizing treatments appropriately to manage Use oxidizing treatments appropriately to manage

chloramines or bromamines chloramines or bromamines Include adequate and optimized ventilation to remove Include adequate and optimized ventilation to remove

DBPs – especially at nightDBPs – especially at night


““Model Aquatic Health Code”Model Aquatic Health Code”from the CDCfrom the CDC

New model code for all types of aquatic facilitiesNew model code for all types of aquatic facilities 13 modules covering all aspects of the facility13 modules covering all aspects of the facility Witten by a consortium of experts from public Witten by a consortium of experts from public

health, academia and industryhealth, academia and industry Main body is written in code language for easy Main body is written in code language for easy

adoption by regulatory agenciesadoption by regulatory agencies Detailed discussion in annex with referencesDetailed discussion in annex with references Rolling release in 2011Rolling release in 2011 www.cdc.gov/healthyswimming/


Minimum disinfectant Minimum disinfectant concentrations in the MAHCconcentrations in the MAHC

DisinfectantPools and other aquatic venues

SpasHigh risk facilities

Free chlorine

1.0 ppm without cyanuric acid

3.0 ppm

Must also use an approved Supplemental Disinfection

System2.0 ppm with cyanuric acid

Total Bromine

3.0 ppm 6.0 ppm

Must also use an approved Supplemental Disinfection

System

(C) 2011 Vore & Associates(C) 2011 Vore & Associates4444

Other parameters in MAHCOther parameters in MAHCParameter Value

Combined chlorine < 0.4 ppm

pH 7.2 to 7.8

Total Alkalinity 80 to 150

Calcium Hardness <400

Cyanuric acid <50 ppm but none in high risk facilities, spas, and indoors

TDS <1500 ppm above initial TDS

Temperature -0.5 to +0.5

Water Balance Spas 104OF, all others <90OF


New manual on RWIs from the New manual on RWIs from the National Swimming Pool FoundationNational Swimming Pool Foundation

Comprehensive review of RWIsComprehensive review of RWIs Discussion more detailed than MAHC annexDiscussion more detailed than MAHC annex Separate chapters on GI, dermal, and Separate chapters on GI, dermal, and

respiratoryrespiratory In depth discussion of minimum disinfectant In depth discussion of minimum disinfectant

levels and remedial treatmentslevels and remedial treatments Will be basis of new operator module from NSPFWill be basis of new operator module from NSPF Due out in summer 2011Due out in summer 2011 www.NSPF.org


General References & ResourcesGeneral References & Resourcestop three web sites likely to be the most usefultop three web sites likely to be the most useful

CDC Healthy Swimming @ CDC Healthy Swimming @ www.cdc.gov/healthyswimming/

National Swimming Pool Foundation @ www.NSPF.org

The Association of Pool and Spa The Association of Pool and Spa Professionals @ Professionals @ http://apsp.orghttp://apsp.org

Guidelines for safe recreational water Guidelines for safe recreational water environments @ environments @ www.who.org


AcknowledgmentAcknowledgment

This seminar was sponsored by Lowry & This seminar was sponsored by Lowry & Associates, Newmarket, ONAssociates, Newmarket, ON

For additional information on testing For additional information on testing please contact Michael Lowry:please contact Michael Lowry: [email protected]@lowryassociates.ca 905-836-0505905-836-0505


Documents

Recreational Water Illnesses: A 2011 Comprehensive Overview Roy Vore, Ph.D., NSPF ® I, CPO ® Vore & Associates LLC [email protected] Michael Lowry,