Abstract
Outbreaks associated with fresh or marine (i.e., untreated) recreational water can be caused by pathogens or chemicals, including toxins. Voluntary reporting of these outbreaks to CDC's National Outbreak Reporting System (NORS) began in 2009. NORS data for 2009-2017 are finalized, and data for 2018-2019 are provisional. During 2009-2019 (as of May 13, 2020), public health officials from 31 states voluntarily reported 119 untreated recreational water-associated outbreaks, resulting at least 5,240 cases; 103 of the outbreaks (87%) started during June-August. Among the 119 outbreaks, 88 (74%) had confirmed etiologies. The leading etiologies were enteric pathogens: norovirus (19 [22%] outbreaks; 1,858 cases); Shiga toxin-producing Escherichia coli (STEC) (19 [22%]; 240), Cryptosporidium (17 [19%]; 237), and Shigella (14 [16%]; 713). This report highlights three examples of outbreaks that occurred during 2018-2019, were caused by leading etiologies (Shigella, norovirus, or STEC), and demonstrate the wide geographic distribution of such outbreaks across the United States. Detection and investigation of untreated recreational water-associated outbreaks are challenging, and the sources of these outbreaks often are not identified. Tools for controlling and preventing transmission of enteric pathogens through untreated recreational water include epidemiologic investigations, regular monitoring of water quality (i.e., testing for fecal indicator bacteria), microbial source tracking, and health policy and communications (e.g., observing beach closure signs and not swimming while ill with diarrhea).
Highlights
Swimmers should observe beach closure signs and water quality advisories, not swim in water made cloudier by heavy rain, not swim while ill with diarrhea, not swallow recreational water, and keep sand out of their mouths
Because of the multiple potential sources of fecal contamination, beach managers and public health officials should educate swimmers and parents of young swimmers about steps they can take to minimize risk of infection from enteric pathogens. These healthy swimming steps include observing beach closure signs or water quality advisories because of elevated levels of fecal indicator bacteria, not swimming in water made cloudier by heavy rain, not swimming while ill with diarrhea, not swallowing the water;,and keeping sand out of mouths
§ CDC’s 2018 Model Aquatic Health Code element 6.3.4.7.1 states “Supervisors shall not permit employees who are ill with diarrhea to enter the water or perform in a qualified lifeguard role.”
Summary
Outbreaks Associated with Untreated Recreational Water — California, Maine, and Minnesota, 2018–2019. On July 22, 2019, the California Department of Public Health was notified of three cases of shigellosis in persons who reported playing in the Santa Ana River, a waterway spanning 100 miles through southern California. Among 19 ill persons for whom epidemiologic data were available, 16 reported that during July 6–August 5 they played in a swim area in a shallow portion of the river where water quality was not regularly monitored. On August 13, 2019, Minnesota Department of Health (MDH) epidemiologists identified three cases of STEC infection in persons who reported swimming at a public lake. The beach was monitored weekly for E. coli throughout the summer, but no test results exceeded Minnesota’s recreational water criteria during April–October.† No evidence of a point source of fecal contamination was identified; 15 visitors and four lifeguards reported continuing to swim or work in the lake while ill. No additional cases were reported after the beach reopened to swimmers on September 5
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