It has excellent sanitation: Winter’s coming so people stop going to the heated pool

I miss the hot tub we had in Kansas.

Yet in the U.S., thousands of public pools, hot tubs are closed each year due to serious violations.

caddyshack.pool.poop-1The U.S. Centers for Disease Control and Prevention reports that inspections of public pools and other aquatic venues enforce standards that can prevent illness, drowning, and pool-chemical–associated injuries such as poisoning or burns.

“No one should get sick or hurt when visiting a public pool, hot tub, or water playground,” said Beth Bell, M.D., M.P.H., director of CDC’s National Center for Emerging and Zoonotic Infectious Diseases. “That’s why public health and aquatics professionals work together to improve the operation and maintenance of these public places so people will be healthy and safe when they swim.”

Inspection data were collected in 2013 in the five states with the most public pools and hot tubs: Arizona, California, Florida, New York and Texas. Researchers reviewed data on 84,187 routine inspections of 48,632 public aquatic venues, including pools, hot tubs, water playgrounds and other places where people swim in treated water.

Among the key findings:

Most inspections of public aquatic venues (almost 80 percent) identified at least one violation.

1 in 8 inspections resulted in immediate closure because of serious health and safety violations.

1 in 5 kiddie/wading pools were closed—the highest proportion of closures among all inspected venues.

The most common violations reported were related to improper pH (15 percent), safety equipment (13 percent), and disinfectant concentration (12 percent).

“Environmental health practitioners, or public health inspectors, play a very important role in protecting public health. However, almost one third of local health departments do not regulate, inspect, or license public pools, hot tubs, and water playgrounds,” said Michele Hlavsa, R.N., M.P.H., chief of CDC’s Healthy Swimming Program. “We should all check for inspection results online or on site before using public pools, hot tubs, or water playgrounds and do our own inspection before getting into the water.”

When visiting public or private pools, swimmers and parents of young swimmers can complete their own inspection using a short and easy checklist that will identify some of the most common health and safety problems:

Use a test strip (available at most superstores or pool-supply stores) to determine if the pH and free chlorine or bromine concentration are correct. CDC recommends:

diaper.poolFree chlorine concentration of at least 1 ppm in pools and at least 3 ppm in hot tubs/spas.

Free bromine concentration of at least 3 ppm in pools and at least 4 ppm in hot tubs/spas.

pH of 7.2–7.8.

Make sure the drain at the bottom of the deep end is visible. Clear water allows lifeguards and other swimmers to see swimmers underwater who might need help.

Check that drain covers appear to be secured and in good repair. Swimmers can get trapped underwater by a loose or broken drain cover.

Confirm that a lifeguard is on duty at public venues. If not, check whether safety equipment like a rescue ring with rope or pole is available.

If you find problems, do not get into the water and tell the person in charge so the problems can be fixed. For more information and other healthy and safe swimming steps, visit

Before CDC-led development of the Model Aquatic Health Code, there were no national standards for the design, construction, operation, and maintenance practices to prevent illness and injury at public treated recreational water venues. Now, local and state authorities can voluntarily adopt these science- and best practices–based guidelines to make swimming and other activities at public pools and other aquatic venues healthier and safer. The second edition of the code will be released during the 2016 swim season. For more information about the Model Aquatic Health Code,

hot.tubProblem/Condition: Aquatic facility–associated illness and injury in the United States include disease outbreaks of infectious or chemical etiology, drowning, and pool chemical–associated health events (e.g., respiratory distress or burns). These conditions affect persons of all ages, particularly young children, and can lead to disability or even death. A total of 650 aquatic facility–associated outbreaks have been reported to CDC for 1978–2012. During 1999–2010, drownings resulted in approximately 4,000 deaths each year in the United States. Drowning is the leading cause of injury deaths in children aged 1–4 years, and approximately half of fatal drownings in this age group occur in swimming pools. During 2003–2012, pool chemical–associated health events resulted in an estimated 3,000–5,000 visits to U.S. emergency departments each year, and approximately half of the patients were aged <18 years. In August 2014, CDC released the Model Aquatic Health Code (MAHC), national guidance that can be adopted voluntarily by state and local jurisdictions to minimize the risk for illness and injury at public aquatic facilities.

Reporting Period Covered: 2013.

Description of System: The Network for Aquatic Facility Inspection Surveillance (NAFIS) was established by CDC in 2013. NAFIS receives aquatic facility inspection data collected by environmental health practitioners when assessing the operation and maintenance of public aquatic facilities. This report presents inspection data that were reported by 16 public health agencies in five states (Arizona, California, Florida, New York, and Texas) and focuses on 15 MAHC elements deemed critical to minimizing the risk for illness and injury associated with aquatic facilities (e.g., disinfection to prevent transmission of infectious pathogens, safety equipment to rescue distressed bathers, and pool chemical safety). Although these data (the first and most recent that are available) are not nationally representative, 15.7% of the estimated 309,000 U.S. public aquatic venues are located in the 16 reporting jurisdictions.

Results: During 2013, environmental health practitioners in the 16 reporting NAFIS jurisdictions conducted 84,187 routine inspections of 48,632 public aquatic venues. Of the 84,187 routine inspection records for individual aquatic venues, 78.5% (66,098) included data on immediate closure; 12.3% (8,118) of routine inspections resulted in immediate closure because of at least one identified violation that represented a serious threat to public health. Disinfectant concentration violations were identified during 11.9% (7,662/64,580) of routine inspections, representing risk for aquatic facility–associated outbreaks of infectious etiology. Safety equipment violations were identified during 12.7% (7,845/61,648) of routine inspections, representing risk for drowning. Pool chemical safety violations were identified during 4.6% (471/10,264) of routine inspections, representing risk for pool chemical–associated health events.

Interpretation: Routine inspections frequently resulted in immediate closure and identified violations of inspection items corresponding to 15 MAHC elements critical to protecting public health, highlighting the need to improve operation and maintenance of U.S. public aquatic facilities. These findings also underscore the public health function that code enforcement, conducted by environmental health practitioners, has in preventing illness and injury at public aquatic facilities.

Public Health Action: Findings from the routine analyses of aquatic facility inspection data can inform program planning, implementation, and evaluation. At the state and local level, these inspection data can be used to identify aquatic facilities and venues in need of more frequent inspections and to select topics to cover in training for aquatic facility operators. At the national level, these data can be used to evaluate whether the adoption of MAHC elements minimizes the risk for aquatic facility–associated illness and injury. These findings also can be used to prioritize revisions or updates to the MAHC. To optimize the collection and analysis of aquatic facility inspection data and thus application of findings, environmental health practitioners and epidemiologists need to collaborate extensively to identify public aquatic facility code elements deemed critical to protecting public health and determine the best way to assess and document compliance during inspections.

Immediate Closures and Violations Identified During Routine Inspections of Public Aquatic Facilities — Network for Aquatic Facility Inspection Surveillance, Five States, 2013

Surveillance Summaries / May 20, 2016 / 65(5);1–26

Michele C. Hlavsa, MPH; Taryn R. Gerth, MPH; Sarah A. Collier, MPH; Elizabeth L. Dunbar, MPH; Gouthami Rao, MPH; Gregory Epperson; Becky Bramlett; David F. Ludwig, MPH; Diana Gomez, MPH; Monty M. Stansbury; Freeman Miller; Jeffrey Warren; Jim Nichol; Harry Bowman; Bao-An Huynh, MPH; Kara M. Loewe; Bob Vincent; Amanda L. Tarrier, MPH; Timothy Shay; Robert Wright; Allison C. Brown, PhD; Jasen M. Kunz, MPH; Kathleen E. Fullerton, MPH; James R. Cope, PhD; Michael J. Beach, PhD

How did the noro get into the bottled water?

Over 4000 illnesses linked to bottled water in Spain and there are a few theories how the virus got into the hundreds of coolers and fridges across the country. Maybe someone puked in the bottling plant, spreading virus particles all over. My money goes on the source.

Whatever the cause, it’s likely little comfort to those who were barfing as a result.

Live Science reports that the thousands of ill folks consumed water cooler water in early April.

It’s possible that norovirus contaminated the water at its source where it was bottled, said Benjamin Chapman, an associate professor and food safety specialist at North Carolina State University, who was not involved in the investigation. In this case, the spring water was bottled in Andorra, a small country located in the Pyrenees mountains between Spain and France.amd-water-cooler-jpg

Norovirus is spread through fecal matter, and in past outbreaks, drinking water became contaminated when sewage leaked into the water source, Chapman said. Given that the recent outbreak in Spain was so large, with hundreds of bottles affected, “it’s more likely that it would be source contamination,” as opposed to contamination at some later point in the bottling process, Chapman said.

Still, it’s also possible that the water was contaminated at the manufacturing facility. Norovirus is a very hardy virus, Chapman said, and if someone with the illness vomited at a bottling facility, this could contaminate equipment used for bottling the water, Chapman said.

Crypto in the US

Cryptosporidium is the leading aetiology of waterborne disease outbreaks in the United States. This report briefly describes the temporal and geographical distribution of US cryptosporidiosis cases and presents analyses of cryptosporidiosis case data reported in the United States for 1995–2012.

cryptoThe Cochran–Armitage test was used to assess changes in the proportions of cases by case status (confirmed vs. non-confirmed), sex, race, and ethnicity over the study period. Negative binomial regression models were used to estimate rate ratios (RR) and 95% confidence intervals (CI) for comparing rates across three time periods (1995–2004, 2005–2008, 2009–2012). The proportion of confirmed cases significantly decreased (P < 0·0001), and a crossover from male to female predominance in case-patients occurred (P < 0·0001). Overall, compared to 1995–2004, rates were higher in 2005–2008 (RR 2·92, 95% CI 2·08–4·09) and 2009–2012 (RR 2·66, 95% CI 1·90–3·73). However, rate changes from 2005–2008 to 2009–2012 varied by age group (Pinteraction < 0·0001): 0–14 years (RR 0·55, 95% CI 0·42–0·71), 15–44 years (RR 0·99, 95% CI 0·82–1·19), 45–64 years (RR 1·47, 95% CI 1·21–1·79) and ≥65 years (RR 2·18, 95% CI 1·46–3·25).

The evolving epidemiology of cryptosporidiosis necessitates further identification of risk factors in population subgroups. Adding systematic molecular typing of Cryptosporidium specimens to US national cryptosporidiosis surveillance would help further identify risk factors and markedly expand understanding of cryptosporidiosis epidemiology in the United States.

Evolving epidemiology of reported cryptosporidiosis cases in the United States, 1995–2012

E. Paintera1 c1, J. W. Garganoa2, J. S. Yodera2, s. A. Colliera2 and M. C. Hlavsaa2

a1 Epidemic Intelligence Service Officer, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA

a2 Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA

Epidemiology and Infection, Volume 144, Issue 8, June 2016, pages 1792-1802, DOI:

Over 1200 sick: Campaign launched to fight Norovirus infection in Philippines

It’s gonna to more than edumacation to “effectively prevent and control the spread of the viral infection in Manila.

dude.wash.handsCity Health Officer Dr. Rodel Agbulos said his office has been saturating the different communities with varied information, education and communication (IEC) materials, through health centers and places of convergence in the different barangays.

Through the declaration, the CHO and other concerned offices and agencies and all health institutions in the city have been directed to institute, undertake and implement curative and proactive measures to effectively address and eradicate the outbreak.

CHO Epidemiology Division Chief Dr. Ivy Iturralde said the aggressive campaign will be focused on the practice of hand washing and proper hygiene.

We just distribute the poop: 3166 sick – probably noro — in Spain linked to bottled water

Gastroenteritis caused by bottled water has affected 3,166 people in Catalonia, according to the regional health department.

05_eden LOGOThe origin of the intoxication is a norovirus that was discovered in bottles distributed throughout Barcelona and Tarragona on April 7, 8, 11, 12 and 13.

The water was drawn from a natural spring called Arinsal, in the principality of Andorra between Spain and France. It was distributed in Catalonia by a company named Eden.

Eden notes that it receives the sealed bottles from Andorra and merely distributes them.

Health authorities are calling all businesses that sold the product in a bid to tally a final number of affected customers. Because the gastroenteritis had mild effects, not all patients went to the doctor, department sources said.

The first tests conducted on patient samples show the presence of a norovirus, a microorganism that is responsible for half of all common gastroenteritis. It is present in animal droppings, which can contaminate the water.

678 sick with gastro linked to bottled water in Spain

The health authority of the northeastern Spanish region of Catalonia says more than 670 people have been affected by an outbreak of gastroenteritis linked to bottled water.

05_eden LOGOThe authority said on its official Twitter account that, as of Saturday, 678 people had been treated for symptoms including nausea, vomiting, abdominal pain, diarrhea and high fever.

Catalonia’s regional health agency said in a statement that bottles of water have been withdrawn from retail outlets and scientific samples are being taken from bottling plants and distributors to determine the source of the outbreak. It did not name the company.

The bottled water company Grupo Eden Springs, however, said in a statement it had withdrawn pallets of bottled water that came from its source in Font d’Arinsal, near Barcelona.

Water and friends

I sometimes retweet my friend Jim Fischer’s accounts of his new ventures as a maple syrup producer (Canadian, eh), B&B entrepreneur, forest management dude, and high school supply teacher.

braunwynn.kittens.03He’s lived a rich life, and will continue. Look at his mother (below, left), 92-years-old and pulling the last syrup off this year’s batch, yesterday.

But when I think of Jim, it’s not his passion for agriculture, his family, or how he always terrified my girls when he delivered chickens by telling them that any cats on his dairy farm would be shot, instantly, to reduce the risk of disease (in fairness, Jim did arrange for us to adopt 3 kittens from the Walkerton animal shelter).

When I think of Jim, it’s how he handled the outbreak of E. coli O157 in Walkerton, Ontario in 2000 that killed seven and sickened 2,500 in a town of 5,000.

“Whenever we heard a helicopter, it probably meant someone else had died.”

That outbreak took a huge toll, in numbers, and in personal memories.

Water, so essential, so precious.

Water safety is vital, and the quality of water important in terms of public health. One of the objectives of the Water Quality and Health Strategy of the World Health Organization (WHO) for the 2013 to 2020 period, is to obtain ‘the most rigorous and relevant evidence regarding water quality and health’ [1].

In terms of infectious diseases, water can transport pathogens in the environment through different steps of the water cycle [2,3]. In the water, some physical or chemical parameters, e.g. temperature, pH, salinity, organic matter, may affect the survival of the pathogens [4]. Substances intended to control pathogens or insects (antimicrobials,  antivirals and pesticides) can occur in water subsequent to their use [5,6] or manufacturing process [7,8]. This may paradoxically induce pathogen or vector resistance to these substances [9-12]. Moreover, water can also bear a number of pathogens with resistance acquired through other pathways [13]. Exposure of people to waterborne pathogens may occur by drinking or swallowing water, inhaling aerosolised droplets and contact with water through bathing and recreation [14,15]. Some pathogens may also be disseminated by water further in the environment (e.g. in the soil and air) potentially allowing human exposure. Consuming foods, grown on/in or irrigated with pathogen-contaminated water may also lead to infection [16,17].

fischer.syrup.apr.16As a number of changes to water, e.g. canalisation, temperature, nutrient enrichment, addition of pest-control or antimicrobial/viral substances, and pathogen contamination, result from human activities, it is relevant to understand their impact on infectious disease epidemiology. To provide some examples relevant for European public health, and to present issues related to the detection and identification of cases of waterborne outbreaks and the proof of anthropogenic change to water as the cause, we issued a call for papers [18]. Subsequent to this, we now publish five articles, through which a number of issues arise and which can be summarised as follows.

The challenges of outbreaks potentially caused by microbial contamination of water are first illustrated in a report from Italy, where an outbreak of monophasic Salmonella Typhimurium 1,4 [5],12:i:- with sole resistance to nalidixic acid is described [19]. Attempts to determine the source of this outbreak led to extensive environmental investigations. While its cause could not be ascertained, a number of surface water samples in the outbreak area, including of water used for growing fruit and vegetables, were positive for the outbreak strain. Moreover some water samples from local sewage treatment plants also tested positive, thus leading to the hypothesis that wastewater may have contaminated irrigation water [19]. The epidemiological investigation was complicated and the origin of the outbreak strain and how this strain acquired its resistance to nalidixic acid remain unresolved. The study reinforces the value of detecting waterborne outbreaks early.

Generally, water may become contaminated from a non-point source, such as the runoff of water from manure in agricultural fields, or from a point discharge, such as a hospital wastewater outlet or a sewage treatment plant. The issue of clinical wastewater harbouring microorganisms resistant to antimicrobials, and its subsequent effect on sewage and freshwater is important for public health, particularly if resistant bacteria introduced in the water can not only survive but also grow in wastewater. Acinetobacter baumanni for example, is considered a nosocomial pathogen, but its ecology is as of yet not fully understood and the observation of community outbreaks has made environmental niches suspect. A study from Croatia finds multiresistant A. baumannii strains in both influent and effluent water to a sewage treatment plant in Zagreb, indicating that such strains can evade the treatment process. The study shows moreover that isolated strains can survive and grow in effluent sewage water up to 50 days, posing a potential risk for further dissemination in the recipient river to the plant [20].

As a risk exists for surface water to become contaminated by wastewater pathogens, there is relevance in fully assessing its safety for further human use. A study from Serbia conducted during the bathing season reveals adenovirus and rotavirus genetic materials in recreational waters of the Danube, along popular public beaches in addition to faecal contamination. As the presence of viruses could not necessarily be predicted by the amount of bacteria measured in the water via routine quality control, the authors conclude that viral indicators may be helpful for further assessing the risks posed by water, in particular in areas where the sewer network is insufficient or inadequate [21].

walkertonWhich panels of viruses could serve as relevant indicators of water quality in certain circumstances would need further investigations, as this may depend in part on their infectivity doses and persistence in environmental water. Also this might require to know what potential viruses contaminate the water to begin with, possibly first requiring agnostic screening techniques. In this regard, the development and implementation of assays that can be used for the surveillance of the whole population of viruses in water samples can be of interest. In this special issue, a methodology combining tangential flow filtration of sewage combined with deep sequencing, without the need for cell culture, is presented as an agnostic approach to survey viruses in sewage. The use of this methodology is proposed for the surveillance of poliovirus, but broader applications, including creating new viral sequence databases for retrospective analysis of presently unknown human viruses that may be discovered in the future are suggested [22].

Should it be a priori known what viruses likely contaminate water in an area, defining more specific tools to confirm their presence may be considered. Moreover in terms of further risk assessment, and as also discussed in the Serbian study in this issue [21], assays to determine the presence of infectious virus might also be of value.

As illustrated by some of the above studies [19,21], adequate management of wastewater is crucial. Indeed, water contaminated by wastewater can subsequently cumulate in larger water bodies such as lakes or the ocean. There, its impact may be less clear, as not only pathogens, but supportive nutrients may be carried by the wastewater. In combination with meteorological factors such as temperature, this may lead to the sporadic or intermittent occurrence of ‘exotic’ or ‘unusual’ pathogens in some areas [4]. An article from the Netherlands describes three cases of Vibrio cholera non-O1 serogroup (VCNO) bacteraemia reported in the country. Cases had been prior exposed to fish and/or had contact with surface water. The Dutch study includes a review of the literature to identify sources and risk factors for bacteraemia [23].

In conclusion, this special issue provides some insights into the importance of surveillance of pathogens in the water [19-23] and outbreaks or cases caused by waterborne pathogens [19,21,23]. Wider studies could help further refine criteria for assessing water treatment processes. Through pollution of ground water with antimicrobials and multi-resistant bacteria, waterborne outbreaks of multi-resistant bacteria are likely to become more frequent in the future. The special issue illustrates that addressing the problems due to anthropogenic changes to water on the epidemiology of human pathogens will require a multi-disciplinary approach.

A note from the editors: impact of anthropogenic changes to water on human pathogens

Eurosurveillance, Volume 21, Issue 15, 14 April 2016

Water suspected: 114 sick with Hepatitis A in Kenya

Mombasa residents are living in fear after the county’s health department confirmed that cases of Hepatitis A infections have risen from 21 to 114 as at Tuesday this week.

mqdefaultCounty officials on Wednesday held a crisis meeting to discuss how the menace will be tackled.

Speaking at the Coast General Hospital on Wednesday, the Mombasa County government Secretary Francis Thoya said that the outbreak has sent county health officials into panic mode.

Thoya said the rate at which the cases are increasing is disturbing, adding that the county is working round the clock to stabilise the situation.

“We have set aside eleven million shillings to tackle the problem before it gets out of hand,” said Thoya.

It’s out of control.

Argentine city suspends classes after gastroenteritis kill girl

In all, 56 schools in Berazategui, in metropolitan Buenos Aires, Argentina, suspended classes on Thursday (14) after a gastrointerite outbreak that has reached 250 people and caused the death of a girl. The suspicion is that the water is contaminated.

water.argentinaIn a statement posted on his Facebook account, the mayor of Berazategui, Juan Patricio Muzzi, announced that colleges will not work for 48 hours to carry out “preventive cleaning and take sample of water tanks and troughs.”

“Last week, we serve more than 250 cases. And second was informed today in the Situation Room led by the holder of borense health folder, Zulma Ortiz, hospital Evita Pueblo, the most affected are children,” reported the mayor in the post .

According to him, the first tests of laboratories indicate the cause of shigella bacteria.

I miss my hot tub, I miss my sauna, I don’t miss the viruses

From August to September 2014 a water quality study was conducted on five popular public Danube beaches in Vojvodina, Serbia.

serbia.beach.waterTo assess the safety of Danube water for bathing, physical, chemical, bacteriological tests were performed. While many parameters for monitoring the quality of water are regulated by law, there are neither national nor international legislations addressing the presence of viruses in recreational waters. In this study, we performed analyses that surpassed national requirements, and investigated if adenovirus, enterovirus or rotavirus genetic material was present in samples of recreational water collected for quality monitoring.

Of 90 water samples obtained during the study, enterovirus material was not found in any sample, but adenovirus and rotavirus genetic materials were respectively detected in 60 and 31 samples. Statistical analyses showed a significant correlation between adenovirus DNA and total coliforms in the water. Even when water samples were adequate for recreational use, adenoviruses were detected in 75% (57/76) of such samples. Our results indicate that implementation of viral indicators in recreational water might be helpful to better assess public health safety. This might be particularly relevant in areas where urban wastewater treatment is insufficient and surface waters affected by wastewater are used for recreation.

Testing For Viral Material In Water Of Public Bathing Areas Of The Danube During Summer, Vojvodina, Serbia, 2014

Eurosurveillance, Volume 21, Issue 15, 14 April 2016

A Jovanović Galović, S Bijelović, V Milošević, I Hrnjaković Cvjetkovic, M Popović, G Kovačević , J Radovanov, N Dragić, V Petrović