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Microbes in Pool Filter Backwash as Evidence of the Need for Improved Swimmer Hygiene — Metro-Atlanta, Georgia, 2012

	MMWR Weekly Volume 62, No. 19 May 17, 2013

Microbes in Pool Filter Backwash as Evidence of the Need for Improved Swimmer Hygiene — Metro-Atlanta, Georgia, 2012

Weekly

May 17, 2013 / 62(19);385-388

Filters physically remove contaminants, including microbes, from water in treated recreational water venues, such as pools. Because contaminants accumulate in filters, filter concentrates typically have a higher density of contamination than pool water. During the 2012 summer swimming season, filter concentrate samples were collected at metro-Atlanta public pools. Quantitative polymerase chain reaction (qPCR) assays were conducted to detect microbial nucleic acid. Pseudomonas aeruginosa was detected in 95 (59%) of 161 samples; detection indicates contamination from the environment (e.g., dirt), swimmers, or fomites (e.g., kickboards). P. aeruginosa detection underscores the need for vigilant pool cleaning, scrubbing, and water quality maintenance (e.g., disinfectant level and pH) to ensure that concentrations do not reach levels that negatively impact swimmer health. Escherichia coli, a fecal indicator, was detected in 93 (58%) samples; detection signifies that swimmers introduced fecal material into pool water. Fecal material can be introduced when it washes off of swimmers' bodies or through a formed or diarrheal fecal incident in the water. The risk for pathogen transmission increases if swimmers introduce diarrheal feces. Although this study focused on microbial DNA in filters (not on illnesses), these findings indicate the need for swimmers to help prevent introduction of pathogens (e.g., taking a pre-swim shower and not swimming when ill with diarrhea), aquatics staff to maintain disinfectant level and pH according to public health standards to inactivate pathogens, and state and local environmental health specialists to enforce such standards.
During June–August 2012, county (Cobb, DeKalb, Fulton, and Gwinnett) and state environmental health specialists collaborated with CDC to collect filter concentrates at a convenience sample of public pools. The study protocol entailed collecting a 1-liter filter backwash* sample 30 seconds after the start of backwash flow and immediately neutralizing any free chlorine (the form of chlorine that inactivates pathogens), using 2.5 mL of a 10% sodium thiosulfate solution. Additionally, the following data were collected using a standardized form: type of filter media; pool location (i.e., indoor versus outdoor), setting (i.e., membership/club, municipal, or waterpark), and primary patron designation (i.e., adults and children versus primarily children); type of disinfectant used; visible signage instructing patrons not to swim when ill with diarrhea; estimated number of swimmers in the past week; and estimated number of days since last filter backwash. No pool identifiers were collected.
During December 2012–March 2013, nucleic acid was extracted from each sample (1), and qPCR assays (Table 1), were conducted to detect nucleic acid of E. coli, P. aeruginosa, Giardia intestinalis, Cryptosporidium spp., E. coli O157:H7 (a pathogenic toxin–producing E. coli), noroviruses GI and GII, and adenovirus.† Detection of a study microbe was defined as a qPCR cycle threshold§ value <40 .="" p=""> All but one of the pool filters in the study were rapid sand filters; the remaining filter used diatomaceous earth. At least one of the assayed microbes was detected in 121 (75%) of 161 filter backwash samples collected. P. aeruginosa was detected in 95 (59%) samples. E. coli was detected in 93 (58%) samples. P. aeruginosa and E. coli were both detected in 67 (42%) samples. G. intestinalis was detected in two samples. Cryptosporidium spp. were detected in one sample. Neither E. coli O157:H7, norovirus GI, norovirus GII, nor adenovirus was detected in any of the samples. The proportion of samples positive for E. coli significantly (p≤0.05) differed between membership/club and municipal pools (Table 2). The proportion of samples positive for P. aeruginosa significantly differed between venues treated with traditional chlorine products combined with ultraviolet light disinfection versus those treated with saltwater-generated free chlorine.¶ Most (71% [10 of 14]) pools with saltwater-generated free chlorine were located outdoors.

Reported by

Christopher Hutcheson, Cobb & Douglas Public Health; Ryan Cira, MPH, Stanley L. Gaines, DeKalb County Board of Health; Kevin R. Jones, MPA, Fulton County Dept of Health Svcs; Walter Howard, David Hornsby, Gwinnett County Health Dept; Maurice Redmond, MS, Chris Rustin, DrPH, Georgia Dept of Public Health. Michele C. Hlavsa, MPH, Jennifer L. Murphy, PhD, Jothikumar Narayanan, PhD, Candace D. Miller, MPH, Brittany Cantrell, MPH, Vincent R. Hill, PhD, Michael J. Beach, PhD, Div of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases. Corresponding contributor: Michele C. Hlavsa, mhlavsa@cdc.gov, 404-718-4695.

Editorial Note

The detection of E. coli in over half of filter backwash samples indicates that swimmers frequently introduced fecal material into pools and thus might transmit infectious pathogens to others. The risk for transmission and recreational water illness (RWI)** increases if swimmers introduce feces when ill with diarrhea (Box). A single diarrheal contamination incident can introduce 107–108 Cryptosporidium oocysts (2) into the water, a quantity sufficient to cause infection if a mouthful of water from a typical pool is ingested (3). Additionally, each person has an average of 0.14 grams of fecal material on their perianal surface that could rinse into the water (4) if swimmers fail to take a pre-swim shower with soap. The 1) frequent occurrence of fecal contamination of pools documented in this study and 2) marked increase in the incidence of RWI outbreaks, which is driven by the substantially increasing incidence of acute gastrointestinal illness outbreaks associated with pools and caused by pathogens transmitted by the fecal-oral route (particularly the extremely chlorine-tolerant parasite, Cryptosporidium) (5), underscore the need for improved swimmer hygiene (e.g., taking a pre-swim shower and not swimming when ill with diarrhea). This study also found that the proportion of samples positive for E. coli significantly differed between membership/club and municipal pools. This finding might reflect differences in the number of swimmers who are either diapered children or children learning toileting skills.
Additionally, more than half of filter backwash samples were positive for P. aeruginosa. The detection of this ubiquitous microbe could reflect environmental (e.g., dirt or pool fill water), swimmer (e.g., fecal material or skin), or fomite (e.g., kickboards) contamination. Once in a pool, P. aeruginosa inhabits and amplifies in biofilms on moist or submerged surfaces, such as pool walls, plumbing, and filters. Further investigation is needed to better characterize P. aeruginosa contamination of pools and its contributing factors. P. aeruginosa can cause RWI (e.g., otitis externa or dermatitis) outbreaks when adequate disinfection is not consistently maintained (5). The proportion of samples positive for P. aeruginosa significantly differed between venues treated with traditional chlorine products combined with ultraviolet light disinfection versus those treated with saltwater-generated free chlorine. The reason for this association is unclear but might reflect differences in swimmers or pool location, age, or design. Pool operator vigilance (e.g., cleaning, scrubbing surfaces, and maintaining water quality [e.g., disinfectant level and pH]) and enforcement of such public health standards by state and local environmental health specialists can minimize P. aeruginosa amplification and thus prevent a negative impact on swimmer health.
The findings in this report are subject to at least four limitations. First, the pools sampled in this study are a convenience sample of pools in metro-Atlanta, and thus study findings cannot be generalized to pools in metro-Atlanta or beyond. However, the incidence of RWI outbreaks of acute gastrointestinal illness throughout the United States suggests that swimmers frequently introduce fecal material and pathogens into recreational water throughout the country. Second, qPCR results alone cannot be used to determine whether the detected pathogens were viable or infectious or determine the level of swimmer risk; qPCR detects viable microbes as well as those inactivated by disinfection. Of note, no RWI outbreaks associated with pools were detected in Georgia in 2012. Third, pool operators were asked to estimate the number of swimmers in the past week and number of days since last filter backwash; however, the data were deemed unreliable and thus could not be used to characterize the relationship between either of these factors and the detection of microbes in filter backwash samples. Finally, E. coli are found in fecal material from warm-blooded animals, not just humans. However, the E. coli detected in the pool filter backwash samples is most likely of human origin given that swimming is the most popular sport among children (6), over one third of the samples that tested positive for E. coli came from filters of indoor pools, and public outdoor pools are fenced in to limit access.
Swimmers have the power and responsibility to decrease the risk for RWIs by practicing good hygiene. In addition to minimizing the amount of fecal material introduced into recreational water, good swimmer hygiene, through bathroom breaks every 60 minutes and taking a pre-swim shower, minimizes the amount of urine and sweat introduced into the water (Box). Nitrogen in urine and sweat depletes free chlorine by combining with it to form di- and tri-chloramines, which are volatile respiratory and ocular irritants; free chlorine alone, at CDC-recommended concentrations, is not an ocular irritant. This study and others indicate that swimmers frequently introduce fecal material, microbes, urine (7), sweat, and other contaminants (8) into recreational water. Another study suggests that disinfectant level and pH frequently are not properly maintained (9). Together, they all underscore the importance of a strong partnership among the swimming public, aquatics staff, and public health to prevent RWIs. RWI prevention will be optimized when swimmers minimize introduction of pathogens into the water by practicing good hygiene, aquatics staff maintain disinfectant level and pH according to state and local public health standards to inactivate pathogens, and state and local environmental health specialists enforce such standards. This critical partnership depends on maintaining robust state and local pool inspection programs (10) that provide leadership by enforcing public health standards and serving as a healthy swimming resource to aquatics staff and swimming public.

Acknowledgment

Joan Shields, CDC, who conducted the first U.S. study of the prevalence of Cryptosporidium spp. and Giardia intestinalis in swimming pools, and who died in December 2012.

References

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2. Goodgame RW, Genta RM, White AC, Chappell CL. Intensity of infection in AIDS-associated cryptosporidiosis. J Infect Dis 1993;167:704–9.
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6. US Census Bureau. Recreation and leisure activities: participation in selected sports activities 2009. Washington, DC: US Census Bureau; 2012. Available at http://www.census.gov/compendia/statab/2012/tables/12s1249.pdf .
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10. National Association of County and City Health Officials. Local health department job losses and program cuts: findings from January 2012 survey. Washington, DC: National Association of County and City Health Officials; 2013. Available at http://www.naccho.org/advocacy/upload/overview-report-mar-2012-final.pdf.

* Contaminants accumulate in pool filters, leading to a decrease in water flow through the filter. Consequently, filters need to be regularly backwashed. Backwashing reverses the direction of the flow of water so that contaminants trapped by the filter are dislodged and discharged to waste.

† CDC does not recommend testing the water or the filter backwash of treated recreational water venues (e.g., pools and hot tubs/spas) for microbes unless the venue is at least suspected to be associated with a waterborne disease outbreak. Maintaining proper disinfectant level and pH should prevent transmission of chlorine-susceptible pathogens.

§ Cycle threshold value is the fractional cycle number reported by real-time PCR instruments indicating the point at which the fluorescence associated with a positive DNA amplification reaction increases beyond the threshold associated with negative reactions.

¶ In saltwater pools, an electric current is passed through the water to generate free chlorine from sodium chloride. This free chlorine is the same as the free chlorine generated when traditional chlorine products are added to pool water.

** RWIs are caused by infectious pathogens transmitted by ingesting, inhaling aerosols of, or having contact with contaminated water in swimming pools, hot tubs/spas, water parks, interactive fountains, lakes, rivers, and oceans. RWIs also can be caused by chemicals in the water or chemicals that volatilize from the water and cause indoor air quality problems.