Potential transmission pathways of clinically relevant fungi in indoor swimming pool facilities

Possible transmission pathways of fungi in indoor swimming pool facilities were assessed through fungal counting in different areas of the facilities and typing of the collected fungal isolates. Air, water and surface samples were collected from seven different indoor swimming pool facilities. Fungal species were identified based on their internal transcribed spacer (ITS) sequences. Maximum fungal concentrations of 6.2?CFU/cm², 1.39?CFU/100?mL, and 202?CFU/m³ were found on surfaces, in water and air, respectively. In total, 458 isolates were obtained, belonging to 111 fungal species, of which 50 species were clinically relevant. Phialophora oxyspora (13.3%) and Trichosporon dohaense (5.0%) were the most frequently isolated species and were merely detected on floors, as were the dermatophytes, Trichophyton interdigitale and T. rubrum. Penicillium spp. and Aspergillus spp. were the dominant fungi in water and air. No typical patterns of fungal concentrations along the preferential pathways of pool visitors were observed, however, sites where pool visitors converge while moving from one room (e.g. dressing room) to another (e.g. shower room) and walking barefoot displayed the highest fungal concentrations thus posing the highest risk of contamination. The dispersal of fungi on floors is most likely facilitated by the pool visitors and cleaning tools. Clinically relevant fungi, including the ones rarely identified in nature, were widely detected on floors, in water and in air, as well as on cleaning tools and flexibeams. Preventive measures such as cleaning should minimize the prevalence of clinically relevant fungi in swimming pool facilities since these potentially pose health risks to those vulnerable for infections.     

An outbreak of cryptosporidiosis associated with a swimming pool.

In August 1988 an increase was noted in the number of cases of cryptosporidiosis identified by the microbiology laboratory at Doncaster Royal Infirmary. By 31 October, 67 cases had been reported. Preliminary investigations implicated the use of one of two swimming pools at a local sports centre and oocysts were identified in the pool water. Inspection of the pool revealed significant plumbing defects which had allowed ingress of sewage from the main sewer into the circulating pool water. Epidemiological investigation confirmed an association between head immersion and illness. The pools were closed when oocysts were identified in the water and extensive cleaning and repair work was undertaken. The pool water was retested for cryptosporidial oocysts and found to be negative before the pool reopened.     

An outbreak of E. coli O157 associated with a swimming pool: an unusual vehicle of transmission

Escherichia coli O157 causes a range of illnesses from mild diarrhoea to haemolytic uraemic syndrome (HUS) which carries a mortality rate of 3.7%. Infection is more common in the under-5s. Between 1995 and 2000, 106 outbreaks of E. coli O157 were reported in England and Wales. Recreational water is well documented as a transmission route for infectious diseases worldwide. In the United Kingdom there have been very few reported outbreaks associated with swimming pools due to the relative susceptibility of E. coli O157 to adequate levels of free chlorine. This report describes the investigation of an outbreak associated with a local leisure centre pool and makes recommendations about the safe management of such facilities.     

Cryptosporidiosis outbreak in a recreational swimming pool in Minnesota

On May 6, 1998, the Olmsted County Public Health Department initiated an investigation into an outbreak of diarrheal illness that had occurred among people who swam frequently at a local swimming pool. Interviews of swimmers and microbiological testing of stool samples and swimming pool filter material were conducted to determine the source of the outbreak. Twenty-six of 206 swimmers interviewed had illnesses that met the case definition. The most common symptoms were diarrhea (100 percent), abdominal cramps (81 percent), and nausea (77 percent). The median duration of symptoms was nine days. Four cases of cryptosporidiosis were confirmed by stool analysis. The outbreak was found to be associated with swimming at the pool. Public awareness-including an understanding that recreational water facilities should be avoided during diarrheal illness-and proper pool hygiene are vital in preventing cryptosporidiosis outbreaks. Health care providers also must consider testing specifically for cryptosporidiosis when a patient presents with persistent diarrhea.     

The study of contents of trihalomethanes in brine of a therapeutic swimming pool and in the swimming pool hall air

The chlorination of iodide-bromide brines during exploitation of therapeutic pools at health resorts brings a hazard of generation of toxic trihalomethanes (THMs), especially bromide derivatives. The study was undertaken to establish the time changes of THM concentration in the pool brine and air in the pool hall. In the pool brine the concentration of THM increased from 40 mg/l at the beginning of the exploitation cycle up to 100 mg/l after 2 months of recirculating the pool water. In the pool hall air the concentration of THM varied from approximately 6 micrograms/m3 to 16.32 micrograms/m3. The values are the concentrations of total THMs per CHCl3, and fall within the range of limits currently admissible for drinking water (so in sport and recreational pools as well). However, they are from 2 to 5 times higher than the admissible level of THMs in indoor pools given in German standards DIN. An interesting finding was over 80% contribution of CHBr3 in the total THMs determined in the pool brine and its 55-59% contribution in the total THMs determined in the pool hall air.     

An outbreak of cryptosporidiosis associated with a resort swimming pool.

An outbreak of cyptosporidiosis occurred in late April 1993 among resort hotel guests which was temporally associated with, but geographically distant from, a massive waterborne outbreak of cryptosporidiosis in Milwaukee, Wisconsin, that occurred in late March and early April of 1993. A case-control study was performed among groups with members who reported illness and among a systemic sample of groups who stayed at the resort hotel during the risk period. Of 120 persons interviewed, 51 (43%) met the case definition. Swimming in the resort hotel''s pool was significantly associated with case status (OR = 9.8; 95% Cl 3.4, 29.7), as was consumption of ice from the hotel''s ice machines (OR = 2.3; 95% Cl 1.01, 5.2). When analysis was restricted only to laboratory-confirmed cases and controls, swimming pool use was the only risk factor significantly associated with illness (OR = 13.0; 95% Cl 2.6, 88.7). Following waterborne outbreaks of cryptosporidiosis associated with water supplies, swimming pools should be considered as possible ongoing sources for transmission regionally.     

Detection of Cryptosporidium oocysts and Giardia cysts in swimming pool filter backwash water concentrates by flocculation and immunomagnetic separation

The purpose of the present study was to evaluate techniques for detection of Giardia cysts and Cryptosporidium oocysts in swimming pool filter backwash water. Calcium carbonate flocculation was used for water samples concentration of 1 l filter backwash water samples. Immunomagnetic separation (IMS) was used for separation of cysts and oocysts from detrital material. Cysts and oocysts were then detected using direct immunofluorescence. ColorSeed C&G was used as an internal standard. Recoveries were examined at several processing points. Highest recoveries (23% Cryptosporidium, 18% Giardia) were obtained using lower filter backwash volumes, greater IMS volumes, and addition of Tween20 to backwash samples prior to processing. The combination of CaCO3 flocculation, IMS and direct immunofluorescence was found to be an effective tool for the detection and quantification of Giardia spp. and Cryptosporidium spp. in filter backwash water samples.     

Nitrates, chlorates and trihalomethanes in swimming pool water.

Water from swimming pools in the Miami area was analyzed for nitrates, chlorates and trihalomethanes. The average concentrations of nitrate and chlorate found in freshwater pools were 8.6 mg/liter and 16 mg/liter respectively, with the highest concentrations being 54.9 mg/liter and 124 mg/liter, respectively. The average concentration of total trihalomethanes found in freshwater pools was 125 micrograms/liter (mainly chloroform) and in saline pools was 657 micrograms/liter (mainly bromoform); the highest concentration was 430 micrograms/liter (freshwater) and 1287 micrograms/liter (saltwater). The possible public health significance of these results is briefly discussed.     

Cryptosporidium and Giardia in swimming pools in the Netherlands

The occurrence of Cryptosporidium and Giardia in indoor swimming pools in the Netherlands was studied at five locations. The backwash water from seven pool filters was analysed for the presence of Cryptosporidium oocysts and Giardia cysts for a period of 1 year. Of the 153 samples of filter backwash water analysed, 18 (11.8%) were found positive for either Cryptosporidium (4.6%), Giardia (5.9%) or both (1.3%). Oocysts and cysts were also detected in the water of one toddler pool and one learner pool. Although most of the (oo)cysts in the filter backwash water were dead, viable and potentially infectious oocysts were detected in the learner pool. On the basis of numbers of potentially infectious (oo)cysts detected in the learner pool, and assuming one visit to an infected pool per year, risk assessment indicated an estimated risk of infection with Cryptosporidium that exceeded the generally accepted risk of one infection per 10,000 persons per year. Guidelines for pool operators on how to manage faecal accidents and public information on the importance of hygiene in swimming pool complexes are recommended tools in controlling the risk of infection.     

Outbreak of norovirus illness associated with a swimming pool

On 3 February 2004, the Vermont Department of Health received reports of acute gastroenteritis in persons who had recently visited a swimming facility. A retrospective cohort study was conducted among persons attending the facility between 30 January and 2 February. Fifty-three of 189 (28%) persons interviewed developed vomiting or diarrhoea within 72 h after visiting the facility. Five specimens tested positive for norovirus and three specimen sequences were identical. Entering the smaller of the two pools at the facility was significantly associated with illness (RR 5.67, 95% CI 1.5-22.0, P=0.012). The investigation identified several maintenance system failures: chlorine equipment failure, poorly trained operators, inadequate maintenance checks, failure to alert management, and insufficient record keeping. This study demonstrates the vulnerability of recreational water to norovirus contamination, even in the absence of any obvious vomiting or faecal accident. Our findings also suggest that norovirus is not as resistant to chlorine as previously reported in experimental studies. Appropriate regulations and enforcement, with adequate staff training, are necessary to ensure recreational water safety.     

Water ingestion during swimming activities in a pool: a pilot study

Chloroisocyanurates are commonly added to outdoor swimming pools to stabilize chlorine disinfectants. The chloroisocyanurates decompose slowly to release chlorine and cyanuric acid. Studies conducted to determine if the chloroisocyanurates might be toxic to swimmers showed that they were not and that ingested cyanuric acid passed through the body unmetabolized. This fact was used to determine the amount of water swallowed during swimming activity. Fifty-three recreational swimmers, using a community swimming pool disinfected with cyanuric acid stabilized chlorine, participated in the study. The participants did not swim on the day before or after the test swim. The swimmers were asked to actively swim for at least 45 minutes and to collect their urine for the next 24 hours. Cyanuric acid was measured in pool water using high performance liquid chromatography and porous graphitic carbon columns with UV detection. The urine sample assay required a clean-up procedure to remove urinary proteins and interfering substances. Results of the study indicate that non-adults ingest about twice as much water as adults during swimming activity. The average amount of water swallowed by non-adults and adults was 37 ml and 16 ml, respectively. The design for this study and the analytical methodology used to assay cyanuric acid in swimming pool water and human urine were effective for measuring the volume of water swallowed during swimming activity.