Elevated bathing-associated disease risks despite certified water quality: a cohort study

Bacteriological water quality criteria have been recommended to ensure bathers' health. However, this risk-assessment approach is based mainly on routine measurements of fecal pollution indicator bacteria in seawater, and may not be adequate to protect bathers effectively. The aim of this study was to assess the risks of symptoms related to infectious diseases among bathers after exposure to seawater which was of excellent quality according to EU guidelines. This study is a cohort study recruiting bathers and non-bathers. Water samples were collected for estimating bacterial indicators. Univariable and multivariable analysis was performed to compare the risks of developing symptoms/diseases between bathers and non-bathers. A total of 3805 bathers and 572 non-bathers were included in the study. Water analysis results demonstrated excellent quality of bathing water. Significantly increased risks of symptoms related to gastrointestinal infections (OR = 3.60, 95% CI 1.28-10.13), respiratory infections (OR = 1.92, 95% CI 1.00-3.67), eye infections (OR = 2.43, 95% CI 1.27-4.63) and ear infections (OR = 17.21, 95% CI 2.42-122.34) were observed among bathers compared with non-bathers. Increased rates of medical consultation and medication use were also observed among bathers. There was evidence that bathers experienced increased morbidity compared with non-bathers though the bathing waters met bacteriological water quality criteria. These results suggest that risk assessments of recreational seawaters should not only focus on bacteriological water quality criteria.     

Caretaker's perceptions, attitudes and practices regarding childhood febrile illness and diarrhoeal diseases among riparian communities of Lake Victoria, Tanzania

Understanding community perceptions and attitudes towards childhood illness is important in developing appropriate interventions. A cross sectional survey was therefore, conducted in a riparian community of Lake Victoria basin in Tanzania to determine caretakers' perception, attitudes and practices on childhood malaria and diarrhoeal diseases. Among 336 caretakers interviewed, 61.1% (205) reported febrile illness in children within three months and 26.0% reported a diarrhoeal episode among children within two weeks before the survey. The majority of the respondents reported high fever (98.7%) and prostration (53.7%) as major symptoms of severe malaria. Convulsions were associated with high fever by only 13.7% of the respondents. Forty percent of the respondents attributed convulsions in children to either fever or malaria, and 24.4% correctly mentioned high fever or malaria. A health facility was the first point of care for childhood malaria for the majority (73%) of the respondents. In diarrhoeal diseases, prostration-weakness (67.7%) and dysentery (20.4%) were commonly reported among the respondents. Typical symptoms of severe dehydration (sunken eyes, loss of skin turgor, dry tears) were poorly recognised as characteristics of severe diarrhoeal diseases. Over 85% of the respondents practiced appropriate dietary measures or increased fluid intake for a child who had diarrhoea. Use of anti-diarrhoea (40.8%) and antibiotic medications (34.8%) were common in the treatment of diarrhoeal diseases. It is important that health education emphasizing recognitions of danger signs/symptoms of malaria and diarrhoeal diseases and their management is strengthened among riparian communities in Lake Victoria basin.     

Nonhygienic behavior, knowledge, and attitudes among interactive splash park visitors

Nonhygienic behavior likely contributed to three recreational waterborne illness (RWI) outbreaks at Idaho splash parks. The study described in this article examined the influence of signage and hygiene attendant presence on rates of nonhygienic behavior among children at splash parks and knowledge and attitudes of their adult supervisors. Investigators observed children for nonhygienic behaviors at four Idaho splash parks, two with signage and attendants. Supervisors were surveyed (N = 551) using an eight-item survey. Individually observed children (N = 145) were often seen exposing their buttocks to splash feature water and placing an open mouth to water. The rate of nonhygienic behaviors was not lower at parks with signage or staff. Supervisors reported bathing children before splash park entry infrequently. Signage and hygiene attendants do not adequately limit nonhygienic behaviors at splash parks, and supervisors have insufficient understanding of RWI. These findings have implica.tions for developing splash park regulations and RWI prevention efforts.     

Longitudinal analysis of symptoms reported by patients with chronic fatigue syndrome

PURPOSE: To determine the effect of chronic fatigue syndrome (CFS) illness duration and onset type on the likelihood of reporting a symptom during successive follow-up periods.METHODS: In 1997, a two-phase RDD survey in Wichita, Kansas, was conducted to estimate the prevalence of CFS. Phase I identified 56,154 respondents 18-69 years of age and screened for severe fatigue, extreme tiredness or exhaustion lasting for 1 month or longer. In phase II an equal number of fatigued (n = 7,176) and randomly selected non-fatigued subjects were asked about 8 CFS and 13 non-CFS symptoms, as well as the presence of specific medical and psychiatric conditions. Eligible respondents were clinically evaluated to establish CFS diagnosis. Phase II respondents were re-contacted at 12- (n = 4,331) and 24-months (n = 4,266) for additional follow-up and diagnosis. In this study we considered symptoms reported as being present most of the time during each successive observation period. Generalized estimating equations were used to model symptoms over time and to address study questions. Such a model accounts for correlations among repeated symptoms for each subject. We used an auto-regressive structure for the correlation matrix, assuming the correlations between each pair of repeated symptoms should decrease as the time between symptoms increased.RESULTS: There were 74 CFS patients who had been ill for 1 to 20 years (median = 6.3 years). Among these, 46 reported gradual and 28 reported sudden onset. Symptoms fluctuated over the course of illness. However, only stomach pain (non-CFS symptom) was more likely to be reported as duration of illness increased (p < 0.05). There was no association between onset type and the likelihood of reporting a symptom during an interview, except that chills and severe headaches were more likely to be reported by sudden cases.CONCLUSIONS: The likelihood of expressing CFS and non-CFS symptom "most of the time" is the same across years of illness. More analyses are warranted to consider expression of symptoms for >/=6 months and severe symptoms.     

Marine waters contaminated with domestic sewage: nonenteric illnesses associated with bather exposure in the United Kingdom.

OBJECTIVES: This study identified possible dose-response relationships among bathers exposed to marine waters contaminated with domestic sewage and subsequent risk of nonenteric illness. METHODS: Four intervention follow-up studies were conducted within the United Kingdom. Healthy volunteers (n = 1273) were randomized into bather and nonbather groups. Intensive water-quality monitoring was used to assign five bacteriological indices of water quality to individual bathers. Illnesses studied were acute febrile respiratory illness, and eye, ear, and skin ailments. RESULTS: Fecal streptococci exposure was predictive of acute febrile respiratory illness, while fecal coliform exposure was predictive of ear ailments. Estimated thresholds of effect occurred at bather exposures above 60 fecal streptococci and 100 fecal coliform per 100 ml of water, respectively. Although no relationship was found between eye ailments and indicator organism exposure, compared with nonbathers, bathers were at higher risk for eye ailments. CONCLUSIONS: Nonenteric illness can be transmitted via recreational contact with marine waters contaminated with sewage. These results argue against the use of a single indicator to establish water quality standards.     

Job insecurity as a risk factor for common infections and health complaints

The aim of this study was to investigate the cross-sectional and longitudinal effect of job insecurity on common infections and health complaints. Self-administered questionnaire data from the Maastricht Cohort Study (n = 12, 140) were used. We used Generalized Estimating Equations analyses to calculate pooled odds ratios (ORs) and 95% confidence intervals. A cross-sectional relationship between job insecurity and common infections or health complaints was found. For the longitudinal relationship, the largest effect was found for flu-like illness (OR 1.39; CI = 1.22-1.57) and health complaints (OR 1.51; CI = 1.39-1.64). We additionally corrected for health behavior, the presence of a long-standing illness, and work-related demands, resulting in lower ORs. An increase in common infections or health complaints has a substantial impact on employee well-being and may result in economic consequences for the company.     

Chronic pain and impairment of function after a sting by the great weaver fish (Trachinus draco)

A 50-year-old fisherman was stung in his right hand by a Great Weever fish (Trachinus draco). The crew did not have sufficient medical knowledge to adequately treat him on board. Severe pain, oedema of the hand, fever, vomiting and syncope occurred. Treatment with antibiotics, on board, after disembarkation and later in hospital for six days reduced the severity of the symptoms. However, two years after the accident, the patient still suffered from a dysfunction of the right hand as well as extreme fatigue and intermittent joint complaints. The symptoms mostly commonly arising from a Weever fish sting are: severe pain, local erythema and oedema. Systemic symptoms may sometimes occur: headache, syncope, bradycardia, fever and hypotension. The symptoms of continuous joint pain and severe fatigue following a Weever sting have not been previously described. The Weever fish venom contains a mixture of biogenous amines, of which some are known: 5-hydroxytryptamine, epinephrine, norepinephrine and histamine. The venom's composition has yet to be fully elucidated. In the event of a Weever fish sting, the first aid which should be given is: clean the wound and immerse the affected part of the body for at least 30 minutes in water which is as hot as the victim can tolerate (40-45 degrees C). Persons at risk from Weever fish stings are bathers, especially from the Lesser Weever fish (Echiichthys vipera), and sea fishermen. General practitioners and first aiders in coastal areas as well as sea fishermen should be informed about the first aid to be given in the event of a Weever sting.     

Recreational water quality in the Caspian Sea

Health-based monitoring of the Caspian Sea in Turkmenistan and Iran suggests that bathers are intermittently subject to increased levels of faecal pollution which may lead to gastrointestinal illness. This is the first co-ordinated monitoring programme of recreational waters in the Caspian region and highlights the need to extend such a programme to all countries bordering the Caspian Sea. The novel approach of monitoring that combines risk assessment (water quality monitoring plus a sanitary survey) and risk management, as applied here, allows the identification of possible sources of pollution and the levels of microbiological risk that bathers are subject to. Hence, this allows suitable management interventions to be identified and implemented in the long-term.     

Outbreaks of short-incubation ocular and respiratory illness following exposure to indoor swimming pools

OBJECTIVES: Chlorination destroys pathogens in swimming pool water, but by-products of chlorination can cause human illness. We investigated outbreaks of ocular and respiratory symptoms associated with chlorinated indoor swimming pools at two hotels. MEASUREMENTS: We interviewed registered guests and companions who stayed at hotels X and Y within 2 days of outbreak onset. We performed bivariate and stratified analyses, calculated relative risks (RR), and conducted environmental investigations of indoor pool areas. RESULTS: Of 77 guests at hotel X, 47 (61%) completed questionnaires. Among persons exposed to the indoor pool area, 22 (71%) of 31 developed ocular symptoms [RR = 24; 95% confidence interval (CI), 1.5-370], and 14 (45%) developed respiratory symptoms (RR = 6.8; 95% CI, 1.0-47) with a median duration of 10 hr (0.25-24 hr). We interviewed 30 (39%) of 77 registered persons and 59 unregistered companions at hotel Y. Among persons exposed to the indoor pool area, 41 (59%) of 69 developed ocular symptoms (RR = 24; 95% CI, 1.5-370), and 28 (41%) developed respiratory symptoms (RR = 17; 95% CI, 1.1-260) with a median duration of 2.5 hr (2 min-14 days). Four persons sought medical care. During the outbreak, the hotel X's ventilation system malfunctioned. Appropriate water and air samples were not available for laboratory analysis. CONCLUSIONS AND RELEVANCE TO PROFESSIONAL PRACTICE: Indoor pool areas were associated with illness in these outbreaks. A large proportion of bathers were affected; symptoms were consistent with chloramine exposure and were sometimes severe. Improved staff training, pool maintenance, and pool area ventilation could prevent future outbreaks.     

Use and abuse of cotton buds

Ear injuries caused by cotton buds are commonly seen in ear, nose and throat (ENT) practice. We asked 1000 patients attending an ENT referral clinic whether they used cotton buds to clean the ear canal. Of the 325 who responded, 171 said they did. The frequency of use was no higher in those with ear complaints than in those with nose and other complaints. 15-20% of respondents disagreed with the statements that cotton buds can cause infections, wax impaction or perforations. On the evidence of this survey, manufacturers' warnings need to be fortified.     

Health beliefs and reported symptoms among a sample of incarcerated adolescent females

Purpose: To understand the health care needs (or perceived needs) of incarcerated female adolescents by comparing their rates of physical complaints, health attitudes, and treatment seeking to a normative sample.Methods: A sample (n = 138) of incarcerated girls was administered the Somatic Symptom Checklist, the Illness Attitudes Scales, and the Reynolds Adolescent Depression Scale to assess lifetime prevalence of physical symptoms, attitudes toward health, treatment-seeking experience, and emotional distress, and allow for comparison with a normative sample. Information regarding length of incarceration, race, and school achievement was obtained from institutional records.Results: A median lifetime prevalence of 12 symptoms for the incarcerated sample differed significantly from the median of six symptoms reported by a normative sample. The symptoms most commonly expressed by the detainees were dizziness, heart pounding, chest pains, and nausea. In both their attitudes toward illness and actual physical complaints, these subjects were more concerned about illness and perceived themselves to be more physically impaired. Self-reported symptoms of depression and illness were positively correlated. Physical complaints were independent of age, race, length of incarceration, or achievement scores.Conclusions: The frequency and variety of somatic complaints, as well as their relationship to emotional distress, among these incarcerated girls highlight the need for integration of physical and mental health services within juvenile facilities.     

Prevalence of mood and anxiety disorders in women who seek treatment for premenstrual syndrome

Many women experience symptoms of premenstrual irritability, reactivity of mood, anxiety, and change in appetite and sleep. Whereas some women experience these symptoms exclusively during the premenstrual phase of the menstrual cycle, others may have premenstrual complaints but actually suffer from mood and anxiety symptoms across the entire menstrual cycle. We sought to determine the extent to which women who seek treatment for premenstrual syndrome (PMS) actually suffer from symptoms of sufficient severity and duration to meet formal criteria for mood or anxiety disorders. Two hundred six women who responded to advertisements for a treatment study of premenstrual dysphoric disorder (PMDD) and who were screened by telephone for study eligibility were included in the current investigation. A telephone questionnaire keyed to the Structured Clinical Interview for Diagnosis (SCID-I/P) was used to screen for the presence of current mood and anxiety disorders. Approximately 39% (n = 80) of respondents met criteria for mood or anxiety disorders or both. Mood disorders were noted almost twice as commonly as anxiety disorders. The high prevalence of mood disorders in the sample underscores the need for clinicians to be aware of the overlap between reported PMS symptoms and underlying depressive disorder. Given that early identification and treatment of mood disorder can increase the likelihood of recovery and lower risk for recurrent illness, clinicians should have a low threshold for ruling out mood and anxiety disorders in women with complaints of premenstrual symptoms.     

Patterns of Illness Behavior Among Rural Elderly: Preliminary Results of a Health Diary Study

This paper summarizes the responses of rural elderly people to a variety of symptoms experienced during a three-week period. Responses to symptoms included causal attributions, consultation patterns, and intervention strategies. Data recorded in diaries during a three-week period highlight the importance of lay care in the illnesses of older people. Most symptoms were managed by older respondents themselves. When symptoms were discussed with someone else, the consultant was most likely a family member or friend rather than a health care professional. Only one third of the respondents contacted any formal provider about any of their symptoms. The majority of respondents combined medical and nonmedical explanations in interpreting their symptoms. The most frequent response to a symptom was doing nothing. The next two most commonly reported interventions were over-the-counter medications and activity limitation. Analyses revealed few differences among residential categories in patterns of illness behavior. Rural-urban differences often disappeared when controlling for demographic and socioeconomic background which covary with residence.     

Health risk of bathing in Southern California coastal waters

Urbanized areas often discharge large volumes of contaminated waste into coastal waters, which may pose a health risk to bathers at nearby beach areas. In this investigation the authors estimated the number of gastrointestinal and respiratory illness episodes associated with the microbial contamination of coastal waters among bathers at Southern California beaches from 2000 through 2004. Bathers at the 67 beaches along the 350-km coastline of Southern California were the study population in this investigation. The authors' estimates were derived from a simulation model, which utilized water quality, beach attendance, and bathing-rate data, along with the three concentration-response relationships that underlie US Environmental Protection Agency, World Health Organization, and European Union marine water-quality guidelines. Given the absence of a general surveillance program to monitor these illnesses in Southern California, simulation modeling provides an established method to derive health risk estimates, despite additional analytic uncertainty that may accompany modeling-based analyses. An estimated 689,000 to 4,003,000 gastrointestinal illness episodes and 693,000 respiratory illness episodes occurred each year. The majority of illnesses (57% to 80%) occurred during the summer season as a result of large seasonal increases in beach attendance and bathing rates. As 71% of gastroenteritis episodes were estimated to occur when the water quality was considered safe for bathing, California's marine water-contact standards may be inadequate to protect the health of bathers.     

Variable effect of vaccination against highly pathogenic avian influenza (H7N7) virus on disease and transmission in pheasants and teals

Highly pathogenic avian influenza viruses can affect many bird species, with disease symptoms ranging from severe morbidity and high mortality to mild transient illness. Much is known about infections in chickens, but for other captive birds the relations between disease symptoms, excretion patterns, and transmission, as well as the effect of vaccination on these relations are not clear. We report results from experimental transmission studies with a highly pathogenic H7N7 virus and two commonly kept bird species (ringed teals and golden pheasants). The results show that depending on the host species the virus can spread in unvaccinated birds with or without disease symptoms. Vaccination reduces disease symptoms markedly, but need not always reduce virus transmission. We discuss the implications for the control of highly pathogenic avian influenza.     

Recurrent symptoms: well-being and management

Although most older adults report one or more symptoms of a chronic health problem, little attention has been paid to the report of these symptoms over time and whether different symptom patterns affect well-being and symptom management in community-dwelling elders. Therefore, this study examined whether community-dwelling older adults in Ohio, U.S.A. who experience consistently recurring (a) arthritis or (b) cardiopulmonary symptoms report more depression and worse self-assessed health and show more symptom management than those who report inconsistent symptoms and if there are differences in well-being and symptom management over time. This secondary analysis used longitudinal data collected from a random sample of 387 older adults who reported their health complaints in four interviews over 27 months time. Subjects were included in this analysis if they reported either arthritis (n = 321) or cardiopulmonary (n = 232) symptoms at one or more times during 27 months, and then were classified as having either consistent (occurring at all four time points) or intermittent/inconsistent (occurring at three or fewer time points) symptoms. Data analysis included t-tests, chi-square tests, and Repeated Measures ANOVA. Results indicate that those with consistent symptoms reported greater depression and worse self-assessed health than those with less consistent symptoms. Specifically, those with consistent cardiopulmonary symptoms became more depressed over time. Those with consistent cardiopulmonary complaints were more likely than those with an inconsistent pattern to use an illness label to describe their symptoms. Those with consistent arthritis symptoms tended to use more self-care at all time points, to label their symptoms as an illness, and were more likely to consult a physician as their symptoms persisted. The implications of symptom recurrence on well-being, symptom management and the concept chronicity are discussed.     

Zoonotic bacteria, antimicrobial use and antimicrobial resistance in ornamental fish: a systematic review of the existing research and survey of aquaculture-allied professionals

Using systematic review methodology, global research reporting the frequency of zoonotic bacterial pathogens, antimicrobial use (AMU) and antimicrobial resistance (AMR) in ornamental fish, and human illness due to exposure to ornamental fish, was examined. A survey was performed to elicit opinions of aquaculture-allied personnel on the frequency of AMU and AMR in ornamental fish. The most commonly reported sporadic human infections were associated with Mycobacterium marinum, while Salmonella Paratyphi B var. Java was implicated in all reported outbreaks. Aeromonas spp. were most frequently investigated (n=10 studies) in 25 studies surveying ornamental fish from various sources. High levels of resistance were reported to amoxicillin, penicillin, tetracycline and oxytetracycline, which was also in agreement with the survey respondents' views. Studies on AMU were not found in our review. Survey respondents reported frequent use of quinolones, followed by tetracyclines, nitrofurans, and aminoglycosides. Recommendations for future surveillance and public education efforts are presented.     

Health effects of attending a public swimming pool: follow up of a cohort of pupils in Paris.

OBJECTIVES--This study aimed to determine the health effects of attending a well-kept school swimming pool maintained according to French public health regulations. METHODS--This prospective month long study was carried out on a randomised sample of pupils aged 5 to 18 years who attended a private French school with two swimming pools. The children surveyed, helped by their parents, had to fill in questionnaires about their bathing habits and symptoms during the survey period. Inspections of the pool complex were made and these included physicochemical and bacteriological analyses of the pools' water. PARTICIPATION--The response rates achieved were 70% at primary and middle school levels but only 25% in the high school pupils. Because of this older teenagers were excluded from the final analysis (of 246 children). RESULTS--Compared with non-bathers, bathers experienced fatigue and eye irritation significantly more often (p < 0.001). The eyes were red (38% of bathers) and/or watery (16%) after swimming but this resolved spontaneously within 24 hours. Bathing behaviour (bath duration, head immersion, wearing swimming goggles) did not affect these incidence rates noticeably. There were no differences between bathers and non-bathers with regard to other symptoms, especially otolaryngological ones. This survey does not allow definite conclusions to be made about verrucas because 22% of non-bathers were exempted from swimming because of verrucas that they might have caught previously in a pool. CONCLUSIONS--Except for verrucas, the methodology was adequate and daily self reporting of symptoms was feasible. This college largely recruits pupils from higher social classes and is not therefore representative of schools in Paris.     

Acceptability of a bilingual interactive computerized educational module in a poor, medically underserved patient population

We evaluated the acceptability and impact of an audiovisual, bilingual, interactive computer module relating to appropriate antibiotic use. In winter 2001, adults seeking urgent care for acute respiratory infections at an inner-city urgent care clinic were invited to complete the computer module and survey (N = 296). After responding to questions about their symptoms, patients were provided information about their illness and appropriate antibiotic use, and then asked several questions about the acceptability of the module. The main outcomes, reflecting qualities known to enhance diffusion of innovations, were "learning something new about colds and flu" and trusting the computer information. Spanish-language respondents (16%) were much less likely to report prior computer experience, more likely to need help, and strongly preferred answering to a person compared with English-language respondents. In multivariable analysis, Spanish-language respondents were more likely to report learning something new (OR = 5.0; 95% CI: 2.0, 12.4) and trusting the information (OR = 2.5; 95% CI: 1.0, 6.0). We conclude that an interactive computer module was well received among a medically underserved urgent care clinic population. Benefits appear greatest among populations having the least experience with this medium.     

Illness in a community associated with an episode of water contamination with sewage.

Following an episode of water contamination with sewage in a rural Irish town, a community-wide survey of gastrointestinal-associated illness and health service utilization was conducted. Random sampling of households yielded residents who were surveyed using a self-administered questionnaire. Of 560 respondents from 167 (84%) households, equal proportions lived in areas known to have been exposed and unexposed to the contaminated water, although 65% of subjects reported using contaminated water. Sixty-one percent of subjects met the case definition. The most common symptoms among cases were abdominal cramps (80%), diarrhoea (75%), appetite loss (69%), nausea (68%) and tiredness (66%). Mean duration of illness was 7.4 days. Only 22% of cases attended their general practitioner. Drinking unboiled water from the exposed area was strongly associated with being a case. A substantial degree of community illness associated with exposure to contaminated water was observed. The episode ranks as one of the largest reported water-borne outbreaks causing gastrointestinal illness in recent times.