Recreational Water Illnesses

## Where Are RWIs Found?

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### Swimming Pools and Other Water Play Areas

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Diarrheal illness is the most common RWI, as stated before. These illnesses are caused by swallowing water that has been contaminated with feces containing germs. Swimmers are the carriers of the germs and the feces that contaminate the water. They share the water with everyone that enters it. On average, people have about 0.14 grams of feces on their bottoms which, when rinsed off, can contaminate recreational water. In addition, when someone is ill with diarrhea, their stool can contain millions of germs. This means that just one person with diarrhea can easily contaminate the water in a large pool or water park. People may not realize that although there is no standing water in interactive fountains/water play areas, the spray water will rinse any contaminants (for example, diarrhea, vomit, and dirt) down into the water holding area and be sprayed again. In other words, the water is recycled through the system. Swallowing even a minuscule amount of contaminated recreational water may make you sick.

### Oceans, Lakes, and Rivers

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Oceans, lakes, and rivers can be contaminated with germs from sewage spills, animal waste, water runoff following rainfall, fecal incidents, and germs rinsed off the bottoms of swimmers. It is important to avoid swallowing the water because natural recreational water is not disinfected. Avoid swimming after rainfalls or in areas identified as unsafe by health departments. Contact your state or local health department for water testing results in your area or go to EPA's beach site.

### Hot Tubs

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Skin infections like "hot tub rash" are a common RWI spread through hot tubs and spas. Respiratory illnesses are also associated with the use of improperly maintained hot tubs.

The high water temperatures in most hot tubs make it hard to maintain the disinfectant levels needed to kill germs. That’s why it’s important to check disinfectant levels [PDF - 98 kb] in hot tubs even more regularly than in swimming pools.

The germs that cause "hot tub rash" can also be spread in pools that do not have proper disinfectant levels and in natural bodies of water such as oceans, lakes, or rivers.

### Decorative Water Features

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Not all decorative water features are chlorinated or filtered. Therefore, when people, especially diaper-aged children, play in the water, they can contaminate the water with fecal matter. Swallowing this contaminated water can then cause diarrheal illness.

## How Are RWIs Spread?

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### Diarrheal Illnesses

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If swimmers are ill with diarrhea, the germs that they carry can contaminate the water if they have an "accident" in the pool. On average, people have about 0.14 grams of feces on their bottoms which, when rinsed off, can contaminate recreational water. When people are ill with diarrhea, their stool can contain millions of germs. Therefore, swimming when ill with diarrhea can easily contaminate large pools or waterparks. In addition, lakes, rivers, and the ocean can be contaminated by sewage spills, animal waste, and water runoff following rainfall. Some common germs can also live for long periods of time in salt water. So, if someone swallows water that has been contaminated with feces, he/she may become sick. Many of these diarrhea-causing germs do not have to be swallowed in large amounts to cause illness.

### Other RWIs

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Many other RWIs (skin, ear, eye, respiratory, neurologic, wound, and other infections) are caused by germs that live naturally in the environment (water, soil). In the pool or hot tub, if disinfectant is not maintained at the appropriate levels, these germs can increase to the point where they can cause illness when swimmers breathe or have contact with water containing these germs. In this podcast, CDC's Dr. Michael Beach discusses the superbug, Cryptosporidium, a common cause of recreational water illness.

## Why Doesn't Chlorine Kill RWIs?

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Chlorine in swimming pools does kill the germs that may make people sick, but it takes time. Chlorine in properly disinfected pools kills most germs that can cause RWIs in less than an hour. Chlorine takes longer to kill some germs such as Crypto, which can survive for days in even a properly disinfected pool. This means that without your help, illness can spread even in well-maintained pools. Healthy swimming behaviors are needed to protect you and your family from RWIs and will help stop germs from getting in the pool.

## Who Is Most Likely to Get Ill From RWIs?

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Children, pregnant women, and people with compromised immune systems (such as those living with AIDS, those who have received an organ transplant, or those receiving certain types of chemotherapy) can suffer from more severe illness if infected. People with compromised immune systems should be aware that recreational water might be contaminated with human or animal waste that contains Cryptosporidium (or Crypto), which can be life threatening in persons with weakened immune systems. People with a compromised immune system should consult their health care provider before participating in behaviors that place them at risk for illness.

## RWI Prevention

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The following information for RWI prevention is from the CDC website, and is about recreational water illnesses and ways to help prevent them is for people who own, manage, operate, or work at pools, waterparks, hot tubs, and spas.

### Twelve steps for reducing germ contamination of swimming pools.

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How can you protect swimmers from recreational water illnesses (RWIs) without restricting access and enjoyment? Consider how pool operators deal with other risks that have been identified at the pool. Problems that have been on deck for years include drowning, injuries, bad weather, and blood spills. Pool operators have adopted risk management strategies that rely on state-of-the-art safety equipment and intensive training of staff. Lifeguards are trained in drowning prevention, rescue, first aid, and policies related to weather use and injury prevention. RWI prevention is no different. It will take a combination of equipment and design improvements, new thoughts on pool policies and management, and critical training and education of staff. However, the responsibility for preventing RWIs does not fall on pool staff alone. Swimmers need to be educated about the necessary behavior changes that they need to make in order to reduce the spread of RWIs. Because this is such a complex problem, pool staff, swimmers and health departments all have a role to play in reducing the spread of RWIs. Integrating the 12 steps for RWI prevention into your current risk management program should help reduce the risk of your pool spreading RWIs.

### 12 Steps for RWI Prevention for Pool Staff

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* Lead your staff.
* Develop partnerships.
* Educate pool staff.
* Educate swimmers and parents.
* Maintain water quality and equipment.
* Evaluate aquatic facility design.
* Institute disinfection guidelines.
* Evaluate hygiene facilities.
* Develop a bathroom break policy.
* Create a special policy for large groups of young children.
* Post and distribute health information.
* Develop an outbreak/emergency response plan.

### STEP 1: Lead your staff.

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Every aquatic facility is different with distinct priorities that have to be juggled on a daily basis while working within limitations on staff and resources. However, all aquatic facilities make safety and health a top priority. Making a choice to integrate an RWI protection plan into an existing facility risk management plan is the single greatest decision you can make to protect swimmers from RWIs. Take the lead, outline your vision, show your commitment to your staff, and put yourself at the forefront of the aquatics field. Decide that RWI protection is a priority; back it up with resource investment and commitment, and that will set the tone for the rest of the staff. Determine which of the Healthy Swimming recommendations are feasible to implement in your facility with available resources. Investing heavily after the outbreak occurs, a common occurrence, is great but it would have been better for the public’s health and more cost-effective if this were done before the outbreak occurred.

### STEP 2: Develop Partnerships

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Building a communication bridge to your health department and other aquatic facilities is a great way to get information about other outbreaks occurring in your community. If you start to hear about outbreaks associated with other pools, daycares, schools, etc., where your swimmers attend, then take proactive measures and increase vigilance to protect your pool. Increase education of staff, swimmers, and visiting daycare groups. If a pool closes because of a suspected outbreak, that does not mean that all of the swimmers should descend on your pool without giving them some education about RWI prevention. Work with your health department to get the word out when a potential RWI outbreak is occurring. Remind them that one of the messages to send out whenever a diarrheal outbreak is occurring is “don’t swim when ill with diarrhea.” Use your communication networks and the media to alert patrons that they should not be swimming if they are ill with diarrhea. Protect your facility, make the contacts early, and build a communication network so that you are aware of the health status of your community at all times.

### STEP 3: Educate pool staff.

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* Ensure that the pool operator, at a minimum, has taken part in a standardized training course given by aquatics professionals.
* Integrate the "Steps" for Healthy Swimming (see poster on next page) into staff training.
* Promote good hygiene and safety around the pool by knowing the "Steps" for Healthy Swimming.
* Inform parents that unhealthy behaviors at poolside and elsewhere are no longer acceptable. Parents told CDC that they wanted to be able to rely on the lifeguards for help and enforcement.
* Ensure that all staff know the critical role of water testing, proper testing methods, and how to respond if disinfectant levels are not adequate.
* Make sure that staff can explain, in a way that is inoffensive and acceptable to parents, why behaviors such as using public tables and chairs for diaper changing is a health risk. This may require that an older, more experienced staff member be assigned to the kiddie pool.
* Maintaining pool water quality according to existing public health requirements will prevent the spread of most recreational water illnesses (RWIs).

### STEP 4: Educate swimmers and parents.

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* Educate your season pass holders. You may choose to begin by educating them first since they may feel more ownership of the facility and want to make the facility as safe as possible.
* Educate your daily patrons. You might hand out prevention messages ("Steps" for Healthy Swimming or CDC brochure) as patrons enter the pool or park area.
* Remember that people care about their health, so a lead-in might be: “To ensure the health and safety of all our visitors, we ask that you remember to follow these easy "Steps" for Healthy Swimming.”
* Consider implementing a short safety and RWI orientation for larger groups before they enter the pool complex. This is especially important for groups with young children (see step ten).

### STEP 5: Maintain water quality and equipment.

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Keep the chemical feed equipment and chemicals at optimal levels within state and local government regulations. This includes maintaining the disinfectant at regulated levels; optimal pH (7.2-7.8); alkalinity (80-120 ppm); calcium hardness (200-400 ppm), and total dissolved solids (below 2500mg/liter). As you know, poor pH control can compromise chlorine’s effectiveness as a disinfectant. Remember that maintaining recommended chlorine levels will prevent most bacterial outbreaks such as E. coli O157:H7. Be sure to monitor chlorine regularly where the chlorine is needed—at poolside. You should be able to prevent waterparks, pools, or hot tubs from running out of chlorine through regular monitoring, and pumphouse and systems checks. Ensure regular and thorough maintenance of the recirculation and filtration equipment to provide maximum filtration.

### STEP 6: Evaluate aquatic facility design.

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Some pools and waterparks have already started to redesign their facilities for the purpose of illness protection. If you are building a new waterpark, get feedback from your industry colleagues and public health experts about the safety and protection features you need to consider in the design stage. Pool designers will respond to you, their customer, if you are clear that your public health needs are a high priority and you consider it an investment in safe operations.

#### Evaluate your filtration system.

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If your kiddie pool filtration system is connected with other pools, fecal contamination can be dispersed from the kiddie pool to the other pools. The best situation is one in which there is a separate filtration system for the kiddie pool. Increasing the water turnover rates in kiddie pools may decrease the length of time that swimmers are exposed to contaminating germs. This decision needs to be made in collaboration with your state and local regulators and design consultants to avoid causing suction injuries. This may require installation of antivortex drain covers (with no top openings and automatic cut-off valves). When it comes to the spread of some illnesses, filtration can help but it takes substantial time to completely filter the pool.

#### Evaluate your form of disinfection.

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There is a great deal of interest in new technologies that disinfect pool water such as ozone, ultraviolet (UV) irradiation, and mixed oxidants. They look promising. Seek out the experts for the latest information but keep in mind that you are still going to need some residual disinfectant in the pool when using ozone and UV.

### STEP 7: Institute disinfection guidelines.

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Even if you are not required to do so, have a written fecal accident response policy and keep records of all fecal accidents, chlorine and pH level measurements, and any major equipment repairs or changes. This may help you respond more efficiently to any problems. You may have little control over a toddler’s soiling your kiddie pool, but you do have control over how you document and respond to this occurrence. It pays to be proactive.

### STEP 8: Evaluate hygiene facilities.

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In CDC’s parent interviews, parents uniformly said they change diapers at poolside because changing rooms were unclean, poorly maintained, and/or had inadequate diaper-changing facilities. Here are some questions that you could ask to improve your facilities:

* Do you have an adequate number of facilities?
* Are the facilities close to the pool?
* Are the facilities well maintained (stocked and cleaned)?
* Would you walk barefoot in them as your patrons do?

Remember….ask your patrons for feedback.

If your facility is large enough, determine the utility of hiring a person just to maintain the restrooms or consider remodeling your diaper-changing stations. Both improvements may be good investments if they increase the number of parents and children who use them.

Install diaper-changing cabanas with soap and running water close by the kiddie pools. This is a great way to discourage parents from changing diapers on tables or lounge chairs. It can also help mothers who are also keeping an eye on other kids. Although difficult, keep pushing to get swimmers to shower (yes, a soap and water, back-end shower) before using the pool. Dirt, sweat, and fecal matter should go down the drain, not into your pool. Train staff to recognize risky behavior such as changing a child on public tables or chairs. Have them educate patrons about why this is a health risk.

### STEP 9: Develop a bathroom break policy.

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CDC hopes to heighten awareness about the transmission of recreational water illnesses (RWIs).

Parents will continue to want to see regular chlorine testing and appropriate disinfection following fecal accidents. Therefore, why not reduce fecal accidents by helping parents get their children to the bathroom by scheduling an hourly break for disinfectant testing and bathroom use? Staff should let patrons know that this break provides optimal timing for bathroom use. Additionally, to prevent transmission of germs, you should ensure that the bathrooms are clean, that they are stocked with toilet paper, and that they have ample soap for hand washing. If parents ask, tell them this policy not only reduces fecal contamination but also should reduce the amount of urine in the pool that uses up disinfectant that could be killing germs.

### STEP 10: Create a special policy for large groups of young children.

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If you allow large groups of diaper/toddler-aged children in the pool (e.g. from daycare centers) consider:

* Requiring RWI orientation training for the care providers and make sure they understand that your pool, like most daycare centers, also excludes children ill with diarrhea.
* Keeping diaper/toddler-aged children in the pools specifically designated for them.

### STEP 11: Post and distribute health information.

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Consider providing signage in a conspicuous location before pool entry.

The sign might state:

* Don’t swim when you have diarrhea.
* Don’t swallow the pool water.
* Wash your hands with soap and water after using the restroom or changing diapers.
* Take your kids to the bathroom often.
* Change diapers in the bathroom and not at poolside.
* Wash your child thoroughly (especially the rear end) with soap and water before swimming.

Encourage swimmers to shower with soap and water before entering the pool. This could reduce the risk of pool contamination by removing invisible fecal matter from their bottoms. A quick rinsing over a swimsuit with cold water will not do much good. Facility staff, managers, and home pool staff should consider having hot water available in shower facilities used by swimmers. The recreational water sector is not the only group that needs to participate in the educational process. Parents have told us that they would like to receive this message from various sources before they arrive at the pool. Public health officials have already begun to educate swimmers by making prevention messages available to the general public.

### STEP 12: Develop an outbreak/emergency response plan.

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The best advice is to be prepared. If an outbreak does occur, are you ready? Do you have a plan?

Most pool staff already have a risk management plan for injuries and drowning, but many do not have plans for managing a recreational water illness (RWI) outbreak.

* Develop a policy to follow in the event that you begin getting calls from the public, or the health department starts an investigation. Part of this plan should include a strategy to communicate with the local health department and media.
* Appoint a spokesperson to ensure that a consistent response is given to outside sources (callers, media, health department, and others), and that these sources have a clear contact person.
* Talk to your colleagues who have experience. It can be difficult if you are not ready to speak with reporters and an outbreak occurs.
* Collaborate with your local health department. This is always important, plus the investigation may indicate a source unrelated to the pool.
* Support the investigation. If the pool is the source of the outbreak, the investigation can often reveal how or why illness was transmitted. This information leads to better illness prevention strategies that can help everyone.

### Steps" for Protection Against Recreational Water Illnesses

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#### Six "Steps" for Protection Against Recreational Water Illnesses (RWIs)

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PLEASE don't swim when you have diarrhea...this is especially important for kids in diapers.

PLEASE don't swallow the pool water.

PLEASE practice good hygiene.

PLEASE take your kids on bathroom breaks often.

PLEASE change diapers in a bathroom and not at poolside.

PLEASE wash your child thoroughly (especially the rear end) with soap and water before swimming.

## Illnesses

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RWIs can include many types of infections that include gastrointestinal, skin, ear, respiratory, eye, neurological, and even wound infection. For best protection and for the most information on these illnesses and the viruses and bacteria that cause them, please visit the links below.

* Cryptosporidium
* Giardia
* Legionella
* Hot Tub Rash
* Swimmer's ear
* Shigella
* norovirus
* E. coli o157:H7

## RWI Prevention Week

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The week before Memorial Day has been designated National Recreational Water Illness (RWI) Prevention Week.The goal of this week is to highlight the simple steps swimmers and pool operators can take to ensure a healthy and safe swimming experience for everyone.

## References

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* http://www.cdc.gov/healthywater/swimming/
* http://wiki.medpedia.com/Recreational_Water_Illness

Center for Disease Control. (2008). Six “PLEAs” For Healthy Swimming: Protection Against Recreational Water Illnesses. Healthy Swimming. Retrieved January, 2009 from http://www.cdc.gov/healthyswimming/6_pleas.htm

Center for Disease Control. (2007). Questions and Answers. Healthy Swimming. Retrieved January, 2009 from http://www.cdc.gov/healthyswimming/w_print.htm

Center for Disease Control. (2007). Swim Diapers and Swim Pants. Healthy Swimming. Retrieved January, 2009 from http://www.cdc.gov/healthyswimming/swim_diapers.htm

Center for Disease Control. (2007). Diarrhea and Spreading Illness at the Pool. Healthy Swimming. Retrieved January, 2009 from http://www.cdc.gov/healthyswimming/diarrhea.htm

Center for Disease Control. (2008). Chlorine Disinfection Time Table. Healthy Swimming. Retrieved January, 2009 from http://www.cdc.gov/healthyswimming/chlorine_timetable.htm

## External links

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* http://www.cdc.gov/healthywater/swimming/
* http://wiki.medpedia.com/Recreational_Water_Illness
* http://www.webmd.com/fitness-exercise/features/beware-of-recreational-water-illnesses
* http://www.rxlist.com/script/main/art.asp?articlekey=115327
* http://www.maine.gov/dhhs/boh/ddc/epi/healthyswimming/
* http://www.dhhs.nh.gov/media/pr/20100524water.htm
* http://www.ok.gov/health/Organization/Office_of_Communications/News_Releases/2010_News_Releases/Recreational_Water_Illness_Prevention_Week,_May_24-30.html
* http://whatisstomachflu.com/how-to-battle-the-effects-of-norovirus/

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