Untreated Recreational Water Research Articles

Outbreaks Associated with Untreated Recreational Water - California, Maine, and Minnesota, 2018-2019.

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).

Norovirus outbreak in a natural playground: A One Health approach.

Norovirus constitutes the most frequently identified infectious cause of disease outbreaks associated with untreated recreational water. When investigating outbreaks related to surface water, a One Health approach is insightful. Historically, there has been a focus on potential contamination of recreational water by bird droppings and a recent publication demonstrating human noroviruses in bird faeces suggested this should be investigated in future water‐related norovirus outbreaks. Here, we describe a One Health approach investigating a norovirus outbreak in a natural playground. On social media, a large amount of waterfowl were reported to defecate near these playground premises leading to speculations about their potential involvement. Surface water, as well as human and bird faecal specimens, was tested for human noroviruses. Norovirus was found to be the most likely cause of the outbreak but there was no evidence for transmission via waterfowl. Cases had become known on social media prior to notification to the public health service underscoring the potential of online media as an early warning system. In view of known risk factors, advice was given for future outbreak investigations and natural playground design.

Assessing the Impact of Cyanuric Acid on Bather’s Risk of Gastrointestinal Illness at Swimming Pools

Current regulatory codes for swimming pool disinfection separately regulate free chlorine (FC) and cyanuric acid (CYA). It is well-known that CYA affects disinfection rates by reversibly binding to FC in aqueous solutions. However, limits for these regulated parameters have neither systematically accounted for this chemistry nor been based on the risk of gastrointestinal illness. This study was intended to determine the minimum concentration of FC relative to CYA based on the risk of gastrointestinal illness from normal fecal sloughing of selected pathogens and to find a simple regulatory rule for jointly managing FC and CYA for consistent disinfection. Literature data on CYA’s effect on microbial inactivation rates were reanalyzed based on the equilibria governing hypochlorous acid (HOCl) concentration. A model was developed that considers the rates of pathogen introduction into pool water, disinfection, turbulent diffusive transport, and pathogen uptake by swimmers to calculate the associated risk of illness. Model results were compared to U.S. Environmental Protection Agency (EPA) untreated recreational water acceptable gastrointestinal illness risk. For Cryptosporidium, correlation between log inactivation and Chick–Watson Ct was far better when C refers to HOCl concentration than to FC (r = −0.96 vs. −0.06). The HOCl concentration had a small variation (± 1.8%) at a constant CYA/FC ratio for typical FC and CYA ranges in swimming pools. In 27 U.S. states, the allowed FC and CYA results in HOCl concentrations spanning more than a factor of 500. Using conservative values for a high bather load pool with 2 mg/L FC and 90 mg/L CYA, the model predicted a 0.071 annual probability of infection for Giardia, exceeding the EPA regulatory 0.036 limit for untreated recreational waters. FC and CYA concentrations in swimming pools should be jointly regulated as a ratio. We recommend a maximum CYA/FC ratio of 20.

Outbreaks Associated with Untreated Recreational Water — United States, 2000–2014

Outbreaks Associated with Untreated Recreational Water — United States, 2000–2014

Outbreaks Associated with Untreated Recreational Water — United States, 2000–2014

Outbreaks associated with untreated recreational water can be caused by pathogens, toxins, or chemicals in fresh water (e.g., lakes, rivers) or marine water (e.g., ocean). During 2000-2014, public health officials from 35 states and Guam voluntarily reported 140 untreated recreational water-associated outbreaks to CDC. These outbreaks resulted in at least 4,958 cases of disease and two deaths. Among the 95 outbreaks with a confirmed infectious etiology, enteric pathogens caused 80 (84%); 21 (22%) were caused by norovirus, 19 (20%) by Escherichia coli, 14 (15%) by Shigella, and 12 (13%) by Cryptosporidium. Investigations of these 95 outbreaks identified 3,125 cases; 2,704 (87%) were caused by enteric pathogens, including 1,459 (47%) by norovirus, 362 (12%) by Shigella, 314 (10%) by Cryptosporidium, and 155 (5%) by E. coli. Avian schistosomes were identified as the cause in 345 (11%) of the 3,125 cases. The two deaths were in persons affected by a single outbreak (two cases) caused by Naegleria fowleri. Public parks (50 [36%]) and beaches (45 [32%]) were the leading settings associated with the 140 outbreaks. Overall, the majority of outbreaks started during June-August (113 [81%]); 65 (58%) started in July. Swimmers and parents of young swimmers can take steps to minimize the risk for exposure to pathogens, toxins, and chemicals in untreated recreational water by heeding posted advisories closing the beach to swimming; not swimming in discolored, smelly, foamy, or scummy water; not swimming while sick with diarrhea; and limiting water entering the nose when swimming in warm freshwater.

Norovirus Outbreak Associated With a Natural Lake Used for Recreation—Oregon, 2014

Norovirus Outbreak Associated With a Natural Lake Used for Recreation—Oregon, 2014

A novel genetic marker for the rapid detection of Bacteroides fragilis in recreational water as a human-specific faecal indicator

Bacteroides spp. has gained substantial interest among the suggested potential candidates for alternative faecal indicators for untreated recreational waters by the US EPA. Interest in Bacteroides as a faecal indicator is based upon the relative abundance of selected members of the Bacteroides genus in the human colon and human faeces. In this study, we developed a real-time PCR detection system based on gyrase B subunit genes (gyrB) specific to Bacteroides fragilis. The gryB-based method was compared with previously described 16S rRNA-based real-time qPCR methods and evaluated for specificity, sensitivity and robustness in detecting B. fragilis from untreated recreational water impacted by human and non-human faecal sources. The new gyrB-based system only detected B. fragilis, whereas the 16S rRNA-based methods generated cross-amplifications with other Bacteroides and Prevotella species. We used a procedure of prefiltration, filtration, sonication and DNA concentration in order to improve the DNA extraction efficiency and the sensitivity of the real-time PCR while removing interference. The amplification and sequencing of PCR products generated by the gyrB-based method confirmed that gyrB-amplified sequences only contained B. fragilis. This rapid method is useful for quantifying faecal contamination and may assist beach and watershed managers in elucidating possible contamination sources.

Disease outbreaks associated with untreated recreational water use

Annual overviews of waterborne disease outbreaks associated with untreated recreational water use provided by authorities responsible for bathing-water quality and public health in The Netherlands revealed 742 outbreaks during 1991-2007 mainly comprising of skin conditions (48%) and gastroenteritis (31%) and involving at least 5623 patients. The number of outbreaks per bathing season correlated with the number of days with temperatures over 25°C (r=0.8-0.9), but was not reduced through compliance with European bathing-water legislation (r=0.1), suggesting that monitoring of faecal indicator parameters and striving for compliance with water-quality standards may not sufficiently protect bathers. Bathing sites were prone to incidental faecal contamination events or environmental conditions that favoured the growth of naturally occurring pathogens. Identification of all possible contamination sources, awareness of changes that might negatively affect water quality, and provision of adequate information to the public are important preventive measures to protect public health.

Outbreaks associated with recreational water in the United States

In this article, we review the causes of outbreaks associated with recreational water during 1971 – 2000. A bacterial or protozoan etiology was identified in three-quarters of the outbreaks; 23% of the outbreaks were of undetermined etiology. The most frequently identified agents were Cryptosporidium (15%), Pseudomonas (14%), Shigella (13%), Naegleria (11%), Giardia (6%), and toxigenic E. coli (6%). Outbreaks attributed to Shigella, E. coli O157:H7, and Naegleria were primarily associated with swimming in fresh waters such as lakes, ponds, and rivers. In contrast, outbreaks caused by Cryptosporidium and Giardia were primarily associated with treated water in swimming and wading pools. Important sources of contamination for both treated and untreated recreational waters were the bathers themselves. Contamination from sewage discharges and wild or domestic animals were also important sources for untreated waters. Contributing factors in swimming-pool outbreaks were inadequate attention to maintenance, operation, disinfection, and filtration. Although not all waterborne outbreaks are recognized nor reported, the national surveillance of these outbreaks has helped identify important sources of contamination of recreational waters and the etiologic agents. This information can affect prevention recommendations and research priorities that may lead to improved water quality guidelines.