By Tom Lachocki
Introduction
An ounce of prevention is worth a pound of cure, but unfortunately, often something bad has to happen before we pull together to create something good.
Over the last decade, documented recreational water illness (RWI) outbreaks have been increasing, according to the U.S. Centers for Disease Control & Prevention (U.S. CDC). The agency documented a record number of RWI outbreaks in the 2001/2002 biannual report (Morbidity and Mortality Weekly Report [MMWR] Oct. 22, 2004). Although perhaps attributable in part to better reporting, the ideal to which we aspire is a decrease in outbreaks.
As our country’s population ages and becomes more sedentary, the need for healthy recreational water facilities increases. But despite this growing need and the increase in RWI outbreaks, most states do not mandate training of people who care for public pools and spas. Budget cuts mean some health departments are funding fewer inspections and not training their staff with nationally-accepted programs that focus on preventing RWI or other injuries.
Taking action
Regrettably, it has taken a major outbreak to initiate change for the better. A community-wide RWI outbreak in Kansas in 2003 prompted the Council of State & Territorial Epidemiologists (CSTE) to ask the CDC to sponsor a national strategic plan to prevent and control RWIs. The CDC, whose competence and leadership on recreational water issues continues to grow, acted on the request with a series of conference calls and a two-day workshop held in February 2005 in Atlanta, Georgia, to establish a draft plan. There, 90 workshop participants represented leading environmental health specialists, epidemiologists, disease investigators, health advocacy groups, academics and aquatic sector representatives. The experts were split into four groups, each with a specific focus:
- What creates the problem of RWI outbreaks?
- How do we increase public awareness to prevent outbreaks?
- How do we maximize the impact of prevention programs?
- What research is needed to improve water treatment, monitoring and management?
Although the CDC has not yet published its final recommendations, both good news and bad news from the working groups’ draft recommendations were presented at the National Environmental Health Association (NEHA) conference in June 2005. The bad news is that some of the goals will take years—possibly decades—to achieve. Some may never be achieved. The good news is that some solutions are already available and can be implemented now.
Establishing a national program to detect and prevent RWI outbreaks is difficult. Part of the challenge is that several groups of people must communicate and cooperate. These include people who care for public and residential pools and spas, retailers, distributors, service companies, manufacturers, health officials, epidemiologists, researchers and medical professionals. In many cases, research is needed to generate data to guide future prevention practices or to create new safety products and processes. Achieving these goals also requires funding during tight budget times.
Despite these challenges, there is greater support from leaders throughout the nation to begin implementing programs considered ‘low-hanging fruit.’ These are initiatives perceived as readily available, inexpensive to implement, or those not requiring excessive personnel.
Understanding RWI outbreaks
We can better understand the RWI problem if we have more effective disease outbreak surveillance in place. However, rapid communication and coordination between local, regional and national officials, medical professionals and the aquatics sector is needed. People who are exposed to, or have ingested contaminated water may not develop symptoms for days, making it difficult to recognize as a RWI. By the time a disease outbreak is recognized, the water chemistry and microbiology have changed. Therefore, good records must be kept at facilities and investigators need expertise in performing investigations.
Fortunately, the CDC now has more information available on its website (http://www.cdc.gov/healthyswimming/outbreak.htm) to assist local health departments in effectively investigating outbreaks. Also, operator training programs consistently advocate thorough record keeping. When an outbreak is suspected, it is important that health officials and facility operators use these tools to better understand the potential causes. Poorly operated facilities with untrained operators are more likely to have RWI and are less likely to have thorough and accurate records. Health departments need to focus more attention on facilities without trained operators and poor records that demonstrate operational problems.
Increasing public awareness
Many consumers do not realize that swimming is a form of communal bathing and that pool and spa waters contain microorganisms. It is not sterile, even when treated with disinfectants like chlorine. Many don’t realize that everybody releases traces of feces and millions of bacteria into the water—even after taking a shower. Surprisingly, some do not realize that swimming when they have, or have recently had, diarrhea places other people at risk. When end users become aware of these facts, they are more likely to practice healthy swimming habits and expect the facility to operate effectively, including properly maintaining water chemistry.
Aquatic facility staff members often avoid these topics because they fear that people will be scared away. Yet, consumers appreciate facilities that are candid and educate their guests on healthy practices. Having the consumer, the facility and the health department working together to maintain a healthy aquatic environment is in each group’s best interest. Some facilities already have communication plans for better consumer education. Many healthy swimming messages are already available and can be used by facilities now. The following information should be communicated to all users of aquatic facilities.
Healthy swimming habits:
- Don’t swim if you have (or have recently had) diarrhea.
- Don’t swallow pool or spa water.
- Don’t swim unless you shower first and wash your hands after using the bathroom during your visit.
- Take children on frequent bathroom breaks.
- Change diapers often and only in the bathroom and not at poolside.
- Wash children with soap and water thoroughly before swimming.
Maximizing prevention programs
Modern civilization is partly defined by its ability to minimize disease among its citizens. The theory behind RWI prevention is relatively simple and training is widely available to help prevent outbreaks. People who are trained are more likely to recognize and prevent RWI. Operator training and certification programs are inexpensive and readily available throughout North America. Training for health officials who inspect pools is available from the NEHA and the National Swimming Pool Foundation (NSPF) in a convenient and inexpensive CD format. This training helps health officials and operators inspect pools thoroughly to reduce risks to users and facility staff.
The need to implement and even require such training is supported by recently-published findings. Maintaining disinfectant throughout the water at all times along with proper circulation and filtration will prevent most RWIs. Many RWI outbreaks are caused by pathogens that are easily inactivated by chlorine (MMWR, Oct. 22, 2004). A recent study shows that many pools (8 percent) and spas (11 percent) were poorly operated and had sufficiently severe violations that they were immediately closed by health department inspectors. More than half of all states do not require the people who operate a pool to be trained and certified by a nationally-accepted training program. Even when regions require trained operators, one study has shown that about one in four operators do not have the proper training (MMWR, June 6, 2003 and July 2, 2004).
Although training helps ensure that operators and inspectors recognize risks and thus can help reduce them, some pathogens pose challenges to even well-run facilities. Cryptosporidium, which is chlorine resistant and small enough to pass through filters, is the cause of many documented disease outbreaks. Research on chlorine-resistant pathogens and the development of new products and practices to prevent RWI are imperative.
Research needs
Historically, there has been insufficient research investment in the recreational water field. Many of the recommended practices in recreational water are based on studies that were developed for drinking water, even though the systems are different. It takes years to identify research gaps, develop proposals, obtain funding, complete the research and implement the findings into new prevention practices or products. Although this is not a quick fix, the National Swimming Pool Foundation® has budgeted to fund as much as $500,000 for grants in 2005. This new funding is in addition to a grant awarded to the CDC for the last two years to understand how to inactivate Cryptosporidium. Preliminary results were presented on Sept. 20-21, 2005, at the World Aquatic Health™ Conference near Los Angeles, Calif.
Conclusion
The pool and spa industry is small, but we have large health issues to overcome. Fortunately, many outbreaks are preventable. We need to use or adapt systems, research and education already available—not waste precious resources reinventing the wheel. We need to build awareness and break down unhealthy practices. We need to educate more and have fewer painful lessons. We need to research more and have less illness. If we succeed, fewer will become ill and more will be attracted to pools and spas. Together, we will increase exercise and decrease disease.
About the author
Thomas M. Lachocki, Ph.D., is CEO of the National Swimming Pool Foundation® (NSPF®), a nonprofit organization founded in 1965 that is committed to improving public health by encouraging healthier living through aquatic education and research. He earned his Ph.D in chemistry from Louisiana State University and his B.S. from Lock Haven University, PA. NSPF is the world’s leading provider of educational programs for North American pool/spa operators and health official through the Certified Pool-Spa Operator® (CPO®) training program, which is available in English, French and Spanish. In addition, NSPF and the National Environmental Health Association have jointly launched the Certified Pool-Spa Inspector™ (CPI™) training program designed for health officials and operators to reduce risks at aquatic facilities. The NSPF disseminates research results and provides advanced training at the World Aquatic Health Conference with speakers from the U.S., Canada & Europe. Research grants and graduate fellowships are available. Information about NSPF programs can be found at www.nspf.org
Reprinted with permission of Pool & Spa Marketing Magazine.