Determinants of bather hygiene in public swimming pools: a mixed-methods analysis of online discussion comments

Swimming in public pools can expose bathers to microbiological (e.g., Cryptosporidium) and chemical (e.g., disinfection by-product) hazards, which can lead to recreational water illness. Adequate hygienic behaviours among bathers are important to reduce these risks. However, prior studies have found low compliance with pre-swim showering and avoidance of urinating in pools. We conducted a mixed-methods analysis of online discussion comments to identify key determinants of these two behaviours. We identified relevant discussion threads on Reddit, Quora, and swimming forums. Identified comments were classified as having a positive or negative sentiment towards the behaviour, and they were thematically analyzed according to the Theoretical Domains Framework (TDF). We analyzed 986 comments from 45 threads; 49.8% of comments were classified as expressing a positive sentiment towards the behaviour. Positive sentiments were more commonly expressed towards pre-swim showering compared to avoidance of urinating in pools (60.1 vs. 47.1%). Eleven themes were identified across the following eight TDF domains: beliefs about consequences (n = 362 comments), social influences (n = 298), beliefs about capabilities (n = 240), social/professional role and identity (n = 144), knowledge (n = 138), emotions (n = 137), reinforcement (n = 78), and environmental context and resources (n = 33). Results can help to inform targeted educational and outreach strategies with bathers to encourage increased adoption of hygienic behaviours.

Precise exposure assessment revealed the cancer risk and disease burden caused by trihalomethanes and haloacetic acids in Shanghai indoor swimming pool water

Swimming pool disinfection byproducts (DBPs) are becoming increasingly common worldwide. Precise exposure and health risk assessment for DBPs in swimming pool water with optimized parameters for local and specific population is more urgently needed. This study aimed to determine the levels of trihalomethanes (THMs) and haloacetic acids (HAAs) in 16 public indoor swimming pools in Shanghai, China. Swimming habits were also investigated to obtain more accurate exposure assessment parameters. Precise exposure assessment through multiple pathways, resulting cancer risk, and disability-adjusted life years (DALYs) were assessed. Results indicated that the highest total level of THMs and HAAs occurred in autumn. The surveyed swimmers 9-17 years of age had higher average daily dose (ADD) of DBPs than swimmers ≥18 years of age. The total lifetime cancer risk (LCR) attributable to THMs and HAAs exceeded 10^-6, which represents a negligible risk level (NRL). The cancer risk from inhalation exposure predominantly by THMs contributed more than 99% of the total risk. Annual disease burden was 19.0 person-years attributed to exposure of DBPs in swimming pool water in Shanghai. This study provides a paradigm and strategic reference of precise exposure assessments, risk assessments, and disease burden estimation of hazards in swimming pool water for other regions.

Regulation, formation, exposure, and treatment of disinfection by-products (DBPs) in swimming pool waters: A critical review

The microbial safety of swimming pool waters (SPWs) becomes increasingly important with the popularity of swimming activities. Disinfection aiming at killing microbes in SPWs produces disinfection by-products (DBPs), which has attracted considerable public attentions due to their high frequency of occurrence, considerable concentrations and potent toxicity. We reviewed the latest research progress within the last four decades on the regulation, formation, exposure, and treatment of DBPs in the context of SPWs. This paper specifically discussed DBP regulations in different regions, formation mechanisms related with disinfectants, precursors and other various conditions, human exposure assessment reflected by biomarkers or epidemiological evidence, and the control and treatment of DBPs. Compared to drinking water with natural organic matter as the main organic precursor of DBPs, the additional human inputs (i.e., body fluids and personal care products) to SPWs make the water matrix more complicated and lead to the formation of more types and greater concentrations of DBPs. Dermal absorption and inhalation are two main exposure pathways for trihalomethanes while ingestion for haloacetic acids, reflected by DBP occurrence in human matrices including exhaled air, urine, blood, and plasma. Studies show that membrane filtration, advanced oxidation processes, biodegradation, thermal degradation, chemical reduction, and some hybrid processes are the potential DBP treatment technologies. The removal efficiency, possible mechanisms and future challenges of these DBP treatment methods are summarized in this review, which may facilitate their full-scale applications and provide potential directions for further research extension.

Assessment of Microbiological Safety of Water in Public Swimming Pools in Guangzhou, China

This study assessed microbiological safety of water from public swimming pools in Guangzhou, China. Water samples from 39 outdoor municipal swimming pools were collected from late June to early September, 2013 and subjected to detection of protozoa (Giardia and Cryptosporidium) and bacteria (Pseudomonas aeruginos, total coliforms, E. coli, E. coli O157, Shigella, and Salmonella). Cryptosporidium and Giardia were both detected in 5 (12.8%) swimming pools. Total coliforms were detected in 4 (10.3%) samples with concentrations ranging from 1.3 to 154.0 MPN/100 mL while E. coli was detected in 4 (10.3%) samples with concentrations ranging from 0.5 to 5.3 MPN/100 mL. P. aeruginosa was detected in 27 (69.2%) samples but E. coli O157, Shigella and Salmonella were not detected. Among these swimming pools, 9 (23%) met the Chinese National Standard of residual chlorine levels and 24 (62%) were tested free of residual chlorine at least once. The multi-locus sequence typing (MLST) analysis showed that all P. aeruginosa isolates belonged to new sequence types (STs) with dominant ST-1764 and ST-D distributed in different locations within the area. Some P. aeruginosa strains were resistant to medically important antibiotics. Results indicate potential public health risks due to the presence of microbiological pathogens in public swimming pools in this area.

[Legal and management issues of public health requirements for swimming pools in Regione Toscana]

In this paper we describe the laws and rules applying to swimming pools. Authorization activity title for recreational swimming pools is regulated according to articles 80 and 86 of the TULPS R.D.n°773/1931. In Regione Toscana periodic management of the hygienic requirements for swimming pools is regulated by Regional Decree 54R/2015. It requires the evaluation of physical-chemical and microbiological indicators. The law applies to structural and organizational requirements of swimming pools as well as defines responsabilities of managers.

First detection of enteric adenoviruses genotype 41 in recreation spring areas of Taiwan

Human adenoviruses (HAdVs) are DNA viruses found in recreational water, such as water parks and swimming pools. Human adenovirus 41 (HAdV-41) is the most common serotype detected and is a leading cause of acute diarrheal disease. The focus of this study is to determine the prevalence of HAdVs in hot springs. Of 57 samples collected from four different geological sites, 16 samples have shown evidence of HAdVs (28.1%). HAdV-41 and porcine adenovirus 5 (PAdV-5) were the two types isolated, with a greater frequency of HAdV-41, which in other settings has been associated with acute diarrhea. The highest occurrence was found in private hot tubs/Yuya (37.5%), followed by an outlet of hot springs (30.8%); public pools and foot pools shared the same detection rate of 21.4% (3/14). However, there was no evidence supporting a link between water quality indicators and HAdV detection rate. From a phylogenic analysis and BLAST against the NCBI database, it was concluded that HAdV-41 obtained from hot spring areas are closely related to global environmental genotypes.

[Some considerations on revision of legislation Hygiene-sanitary for the management of swimming pools for swimming-pool use and the National Consultation of the Ministry of Health]

After over a decade the Italian regulation on hygiene and surveillance in swimming pools is under revision based on WHO guidelines and current laws from other European countries. The Ministry of Health is proposing an update of the Annex 1 that contains physical, chemical and microbiological indicators for monitoring swimming pool hygiene. The authors review current regulations and the new proposal for updating surveillance. A comparison of Annex 1 as approved in 2003 and the new version as proposed in 2016 allowed to enlighten innovative improvements. The suggested updates underwent a public consultation through an online questionnaire involving citizens and stakeholders, following the required procedure for accessing the final approval of a new regulation. The updates include new requirements and changes involving several controls and microbiological parameters. Safety of recreational waters is presently under revision in different European countries. This updating process is a valuable opportunity to implement critical control points and improve monitoring. The final aim is an optimization of surveillance in terms of efficacy and costs, with an advantage for both the National Health Service as the swimming pool management.

Bacteriological quality of some swimming pools in Alexandria with special reference to Staphylococcus aureus

Swimming pools have been identified as posing some public health risks to users due to either bacterial or chemical contamination. As a result, maintaining good swimming pool water quality is an important issue in preventing health risks for bathers. This study aimed to evaluate the bacteriological quality of some swimming pools in Alexandria and to investigate the prevalence of Staphylococcus aureus (S. aureus) in water samples. A total of 120 water samples from 10 swimming pools were collected. Bacteriological analysis included heterotrophic plate count (HPC) using pour plate method; enumeration of total coliforms (TC), Escherichia coli (E. coli) and S. aureus by membrane filtration technique. Antimicrobial susceptibility testing was performed on isolated S. aureus. Residual chlorine and pH were measured at swimming pools side. HPC was the least complying microbial parameter, followed by TC. S. aureus was recovered from 18 samples; 9 isolates were methicillin resistant S.aureus (MRSA), compared to E. coli that was detected in 7 samples. HPC and TC showed statistically significant correlations with all investigated parameters. In conclusion, the examined pools showed poor quality regarding all examined parameters collectively according to the Egyptian guidelines, which necessitates implementation of proper measures to ensure safer environment in swimming pools.

Predicting bromide incorporation in a chlorinated indoor swimming pool

The water in and air above swimming pools often contain high levels of disinfection byproducts (DBPs) due to chemical reactions between chlorine- or bromine-based disinfectants and organic/inorganic matter in the source water and released from swimmers. Exposure to these DBPs, though inevitable, can pose health threats to humans. In this study, DBPs in tap water (S1), and water from a chlorinated indoor swimming pool before (S2) and after swimming (S3) were measured. The brominated species constituted the majority of DBPs formed in S1, S2, and S3. Trihalomethanes (THMs) in S3 was 6.9 (range 2.9-11.1) and 1.4 (range 0.52-2.9) times those in S1 and S2, respectively; and the haloacetic acids (HAAs) in S3 was 4.2 (range 2.5-7.5) and 1.2 (range 0.6-2.6) times those in S1 and S2, respectively. The mean THMs in air above the swimming pool before (S2-A) and after swimming (S3-A) were 72.2 and 93.0 μg/m(3), respectively, and their ranges were 36.3-105.8 and 44.1-133.6 μg/m(3), respectively. The average percentages of bromide incorporation (BI) into THMs in S1, S2, and S3 were 3.0, 9.3, and 10.6 %, respectively; and the BI into HAAs in S1, S2, and S3 were 6.6, 12.0, and 12.2 %, respectively. Several models were trained for predicting the BI into THMs and HAAs. The results indicate that additional information is required to develop predictive models for BI in swimming pools.

Estimated environmental radionuclide transfer and deposition into outdoor swimming pools

In 2011, a large radioactive discharge occurred at the Fukushima Daiichi nuclear power plant. This plant is located within a climatically temperate region where outdoor swimming pools are popular. Although it is relatively easy to decontaminate pools by refilling them with fresh water, it is difficult to maintain safe conditions given highly contaminated diurnal dust falls from the surrounding contaminated ground. Our objectives in this paper were to conduct daily radioactivity measurements, to determine the quantity of radioactive contaminants from the surrounding environment that invade outdoor pools, and to investigate the efficacy of traditional pool cleaners in removing radioactive contaminants. The depositions in the paper filterable particulates ranged from 0 to 62,5 Bq/m(2)/day, with the highest levels found in the southern Tohoku District containing Fukushima Prefecture and in the Kanto District containing Tokyo Metro. They were approximately correlated with the ground contamination. Traditional pool cleaners eliminated 99% of contaminants at the bottom of the pool, reducing the concentration to 41 Bq/m(2) after cleaning. Authors recommended the deposition or the blown radionuclides into outdoor swimming pools must be considered into pool regulations when the environments exactly polluted with radionuclides.

Decontamination of outdoor school swimming pools in Fukushima after the nuclear accident in March 2011

Because of radioactive fallout resulting from the Fukushima Daiichi Nuclear Power Plant (NPP) accident, water discharge from many outdoor swimming pools in Fukushima was suspended out of concern that radiocesium in the pool water would flow into farmlands. The Japan Atomic Energy Agency has reviewed the existing flocculation method for decontaminating pool water and established a practical decontamination method by demonstrating the process at eight pools in Fukushima. In this method, zeolite powder and a flocculant are used for capturing radiocesium present in pool water. The supernatant is discharged if the radiocesium concentration is less than the targeted level. The radioactive residue is collected and stored in a temporary storage space. Radioactivity concentration in water is measured with a NaI(Tl) or Ge detector installed near the pool. The demonstration results showed that the pool water in which the radiocesium concentration was more than a few hundred Bq L was readily purified by the method, and the radiocesium concentration was reduced to less than 100 Bq L. The ambient dose rates around the temporary storage space were slightly elevated; however, the total increase was up to 30% of the background dose rates when the residue was shielded with sandbags.

[Microbial risk assessment of urban water bodies for aesthetical and recreational uses]

With the increasing public access to urban water bodies for aesthetical and recreational purposes, it is of critical importance for densely populated urban areas to conduct microbial risk assessment and accordingly implement effective risk management. Based on the methodology of quantitative microbial risk assessment, a case study was conducted on three typical urban water bodies for aesthetical and recreational uses in a southern city in China. Exposure assessment was carried out through water quality monitoring, field survey and literature review, and accordingly human health risk was assessed with different dose-response equations based on fecal coliforms (FC), Escherichia coli (EC) and Enterococci (ENT). Microbial risk estimated by different dose-response equations was found consistent with and comparable to each other. Stream B located in a residential area was not suitable for primary- or secondary-contact recreational uses, and its microbial risk to the public mainly came from water abstraction for household miscellaneous uses. Stream C and Lake E, located in a public open space and a scenic area respectively, could meet the current recreational requirements, and their microbial risk to the public was generally attributed to various recreational activities. It was necessary to address the public health risk associated with the unauthorized or inappropriate water uses (e.g. abstraction for household miscellaneous uses) of urban aesthetical and recreational water bodies.

Assessment of water quality of some swimming pools: a case study in Alexandria, Egypt

In spite of the importance and popularity of swimming pools in summer, they have been identified as posing some public health risks to users due to either chemical or microbiological contamination. This study was carried out aiming at assessing the quality of water for some Alexandria's swimming pools in order to determine its compliance with the Egyptian standards no. 418/1995. Five swimming pools were selected randomly from different districts. Physical and chemical parameters, as well as biological examination of a total of 30 samples, were carried out using standard analytical methods. Water samples were collected from the studied swimming pools monthly over 6 months and pool water monitoring was carried out during afternoon of the weekends when the pools were most heavily used. The results indicated overall poor compliance with the standards. Compliance of the pool water to the microbial parameters, residual chlorine, pH, and turbidity were 56.7% (17 samples), 20% (6 samples), 46.7% (14 samples), and 46.7% (14 samples), respectively. Statistical analysis showed significant association between water contamination with microbial indicators and physical-chemical aspects such as residual chlorine, temperature, turbidity, and load of swimmers. Furthermore, Cryptosporidium oocysts and Giardia lamblia cysts has been found in 10% of samples. It was concluded that there is a need to improve disinfection and cleaning procedures, with consideration given to safety, and size of the pool in relation to bathing load. There is also a need to monitor swimming pool water quality continuously, and to increase bather hygienic practices and awareness of the risks as well as training of governmental inspectors.

[Evaluation of the informativity of indices of the sanitary-epidemiological safety of the swimming pools]

Water samples and surface swabs from 15 Moscow public indoor swimming pools (SP), where disinfection was carried with the use of chlorine reagents, were studied and excess of bacteriological indicators standards was revealed, infestants of fungous skin and nails diseases were allocated. The research results showed both the absence of epidemic significant information value of bacteriological indicators in relation to infestants of fungous diseases and discrepancy of efficiency of existing recommendations for disinfection actions to requirements on providing sanitary-and-epidemiologic safety of SP visitors.

A risk assessment of Pseudomonas aeruginosa in swimming pools: a review

Despite routine monitoring and disinfection, treated swimming pools are frequently contaminated with the opportunistic pathogen Pseudomonas aeruginosa, which can represent a significant public health threat. This review was undertaken to identify the current understanding of risk factors associated with pool operation with respect to P. aeruginosa. The ecology and factors that promote growth of P. aeruginosa in the pool environment are complex and dynamic and so we applied a systematic risk assessment approach to integrate existing data, with the aim to improve pool management and safety. Sources of P. aeruginosa, types of infections, dose responses, routes of transmission, as well as the efficacy of current disinfectant treatments were reviewed. This review also highlights the critical knowledge gaps that are required for a more robust, quantitative risk assessment of P. aeruginosa. Quantitative risk management strategies have been successfully applied to drinking water systems and should similarly be amenable to developing a better understanding of the risk posed by P. aeruginosa in swimming pools.

Microbiological and chemical indicators of water quality in indoor hotel swimming pools before and after training of swimming pool operators

The present study was undertaken in order to determine the quality of indoor pool waters in hotels along the Croatian coast. We wanted to assess the risks of exposure to microbial and chemical contaminants and find out if training pool operators to use a quality assurance system, that we developed, influenced hygienic conditions and water quality in swimming pools or not. The samples were analysed for free chlorine, pH and several microbiological indicators according to standard laboratory methodologies. Of 1,329 samples tested, 276 were found to be unacceptable either by chemical (148) or microbiological parameters (128). After training, the proportion of unacceptable samples dropped by 23.5%, mostly according to the free chlorine values. According to our results, most of the microbiologically unacceptable samples had chlorine levels within the recommended range but their pH values were too high. A free chlorine level below 0.2 mg/L was found in 106 (82.8%) microbiologically unacceptable samples suggesting the need for maintaining the lower limit at least above 0.2 mg/L in order to reduce microbial risks to a more acceptable level. This measure combined with training of pool operators might result in reduced health risks in pool waters.

[New rules of the bathing water quality management]

Directive 2006/7/EC concerning the management of bathing water quality and repealing directive 76/160/ EEC, adopted in 2006, resulted in changes polish laws and regulations of this topic, which were necessary to comply with the new Directive. These included Water Act and three regulations: on bathing water quality surveillance, on bathing waters register and on bathing water profile. The main changes in the sanitary surveillance on bathing waters quality and their consequences for bathers has been discussed in the article. According to new regulations conducting bathing water quality monitoring was handed over to organizers of bathing sites and local government. Bathing water supervision and water quality assessment is in Polish Sanitary Inspection competence. Unique solution of polish law is division of bathing places into two categories: bathing sites and places used for bathing. In a consequence regulations "create" another category of such objects like places used according to custom for bathing by neighbourhood people, which will be left without any supervision. There is significant threat that new formal aspects combined with organisers burdened with supervision and finance responsibilities, will lead to decrease number of bathing sites in favour of growing number of places used for bathing. This can in consequence diminish bathers health safety.

Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes

BACKGROUND

Aquatic and land based exercise are frequently prescribed to maintain function for people with arthritis. The relative efficacy of these rehabilitation strategies for this population has not been established.This review investigated the effects of aquatic compared to land based exercise on function, mobility or participants' perception of programs for people with arthritis.

METHODS

Medline, CINAHL, AMED and the Cochrane Central Register of Controlled Clinical Trials were searched up to July 2010. Ten randomised, controlled clinical trials that compared land to aquatic exercise for adults with arthritis were included. Study quality was assessed with the PEDro scale. Data relevant to the review question were systematically extracted by two independent reviewers. Standardised mean differences between groups for key outcomes were calculated. Meta-analyses were performed for function, mobility and indices that pooled health outcomes across multiple domains.

RESULTS

No differences in outcomes were observed for the two rehabilitation strategies in meta-analysis. There was considerable variability between trials in key program characteristics including prescribed exercises and design quality. Components of exercise programs were poorly reported by the majority of trials. No research was found that examined participant preferences for aquatic compared to land based exercise, identifying this as an area for further research.

CONCLUSION

Outcomes following aquatic exercise for adults with arthritis appear comparable to land based exercise. When people are unable to exercise on land, or find land based exercise difficult, aquatic programs provide an enabling alternative strategy.

Assessing bacteriological contamination in public swimming facilities within a Colorado metropolitan community

An increase in waterborne disease outbreaks and illnesses related to public swimming facilities in the past few decades prompted a Colorado metropolitan public health and environment division to assess bacteriological contamination of local public swimming facilities and determine if routine bacteriological sampling may be warranted. In the study discussed in this article, 27 chlorinated public swimming facilities were sampled twice within two consecutive weeks for total coliform, fecal coliform, and heterotrophic plate count (HPC) bacteria. Data from this study suggest that 11% of the public swimming facilities were in excess of public health standards for total coliform bacteria and that 18.5% of the public swimming facilities were in excess of public health standards for HPC bacteria. According to the research data and the reviewed literature, the results indicate that the contamination observed in excess of public health standards was most likely the result of inadequate water treatment operations and activities.

[Problems of sanitary-and-epidemic safety of swimming pools in Moscow]

Due to the fact that swimming pools are widely used as sports and fitness objects and that their construction is growing in the public and individual sectors, there is an increasing need for more effective sanitary and microbiological monitoring of the epidemic safety of bathers against not only enteral infections, but also infectious diseases of the skin, mucosae, and nail plates, including onychomycosis. The data available in the literature and the authors' findings indicate that swimming pool attendance might be a reason for the spread of mycosis pathogens and necessitates the development of standards for these indicators and a search for novel promising disinfectants.

[Environmental surveillance of a sample of indoor swimming pools from Emilia Romagna region: microclimate characteristics and chemical parameters, particularly disinfection by products, in pool waters]

The aim of the present study was to investigate the environmental and healthy aspects from a representative sample of indoor swimming pools located in the Emilia Romagna region. During the sampling sessions, the occupational environment was evaluated in terms of microclimate parameters and thermal comfort/discomfort conditions. Moreover the chemical risk was assessed by analyzing from the pool water the presence of disinfection by-products (DBPs), such as: trihalomethanes (THMs), haloacetic acids (HAAs), chlorite, chlorate and bromate. The analytical results are in agreement with the Italian legislation (Accordo Stato-Regioni; 2003) even if in some of the sampled indoor swimming pools, the dosed combined chlorine levels, were greater than the Italian limit. With the regard to the microclimate conditions evaluation, the considered thermal indices, Predicted Mean Vote (PMV) and Predicted Percentage of Dissatisfied (PPD%), described a satisfactory occupational environment. Among DBPs, the THMs mean levels (41.4 +/- 30.0 microg/l) resulted close to the values of the current Italian drinking water legislation, and seem to not represent an health issue. The pool waters chlorate levels (range: 5 - 19537 microg/l) need further investigations as recent epidemiological studies on drinking water hypothesized a potential genotoxicity effect of these compounds which are involved in cellular oxidative processes.

Prevention of drowning in home pools – lessons from Australia

As an affluent and warm weather country, Australia faced an epidemic of drowning in children under five as the popularity of home pools increased in the late 1960s and early 1970s. In one state child drowning rose by 6.62 per 100,000 in the five years from 1968. Variation across jurisdictions in actions to regulate domestic pools has resulted in Australia representing an unfortunate natural experiment in interventions to prevent child drowning in pools. Mechanisms adopted by various authorities were analysed in detail to identify factors that contributed to success and failure in regulating domestic pools. Despite early identification of the problem and development of what were later demonstrated to be effective interventions, best practice solutions were not established in any jurisdiction until 2002, 25 years after identification of the problem. Key failures in intervention were found to be: failure to act in a timely way, flawed regulation, blockage of timely action and repeal of effective state regulation under political pressure, and blockage of effective standards. Lessons are identified as: inherent weaknesses in the standard setting process, failure of interventions to address major risk categories, failure to act before the hazard grew, failure to consider lesser interventions for tactical reasons, failure to pay attention to advocates, and the need for continuing effort. The paper argues that analysis of the identification of the problem, development of interventions and implementation of mechanisms of prevention illustrate where systemic changes are required and indicate lessons that should be applied in developing and implementing future interventions.

[Hygienic profile of the water in Milan swimming pools: a three-year comparative study]

The aim of this work was to determine whether swimming pool water quality in Milan from 2006 to 2008 was within the standards established by national and local Italian laws (Circolare Min. Sanità 128/71 and DGR 2552/2006). In 2006, 580 samples of water from public swimming pools were analyzed to determine the presence of heterotrophic counts at 37 degrees and total coliforms; pH, free chlorine and chloride of each sample were also measured. In the following years, water from both public and private swimming pools were examined to measure heterotrophic count at 22 degrees and 36 degrees, Escherichia coli, enterococci, Pseudomonas aeruginosa, Staphylococcus aureus, pH, free chlorine, and nitrates. The total number of analyses carried out in 2007 and 2008 was 2074 and 1532, respectively. In 2006, the extent of noncompliance of all swimming pools that was observed for both physical/chemical and microbiological parameters was 72.3%, which then decreased to 53.2% and 36.2% in 2007 and 2008, respectively. In particular with regard to the microbiological analysis, an increase of noncompliance based on at least one parameter was determined (7.1% in 2006 vs. 21.5% in 2007 and 22% in 2008). In contrast, a decrease of the extent of noncompliance based on at least one physical/chemical parameter was observed (from 68.1% in 2006 to 40.4% and 22.3% in 2007 and 2008, respectively). Interestingly, public swimming pools exceeded the legal limits of microbiological concentration more often than the private ones, whereas both types of swimming pools showed a decrease in noncompliance with regard to the physical/chemical parameters.

Centers for Disease Control and Prevention (CDC). Violations identified from routine swimming pool inspections--selected states and counties, United States, 2008

Swimming is the third most popular U.S. sport or exercise activity, with approximately 314 million visits to recreational water venues, including treated venues (e.g., pools), each year. The most frequently reported type of recreational water illness (RWI) outbreak is gastroenteritis, the incidence of which is increasing. During 1997--2006, chlorine- and bromine-susceptible pathogens (e.g., Shigella and norovirus) caused 24 (23%) of 104 treated venue--associated RWI outbreaks of gastroenteritis, indicating lapses in proper operation of pools. Pool inspectors help minimize the risk for RWIs and injuries by enforcing regulations that govern public treated recreational water venues. To assess pool code compliance, CDC analyzed 2008 data from 121,020 routine pool inspections conducted by a convenience sample of 15 state and local agencies. Because pool codes and, therefore, inspection items differed across jurisdictions, reported denominators varied. Of 111,487 inspections, 13,532 (12.1%) resulted in immediate closure because of serious violations (e.g., lack of disinfectant in the water). Of 120,975 inspections, 12,917 (10.7%) identified disinfectant level violations. Although these results likely are not representative of all pools in the United States, they suggest the need for increased public health scrutiny and improved pool operation. The results also demonstrate that pool inspection data can be used as a potential source for surveillance to guide resource allocation and regulatory decision-making. Collecting pool inspection data in a standardized, electronic format can facilitate routine analysis to support efforts to reduce health and safety risks for swimmers.

[Problems in harmonization of hygienic requirements for swimming pools with the international recommendations]

The paper considers the ways of harmonizing the hygienic requirements for the safe use of swimming pools. It proposes a procedure for substantiating the safe use of water disinfectants on the basis of real exposure factors, by bearing in mind their complex action. The proposed procedure is comparatively assessed with the methods and criteria laid down in foreign normative documents.

[Water decontamination in the swimming pools: standardization and practice]

Practical examples were used to analyze possible ways and regimens of water decontamination with chlorine and ozone in the swimming pools when oxidants substantially interacted with the mineral and albuminoid ammonias that were present in the water. Ozone water decontamination was shown to be more effective than water chlorination and to rule out the generation of chloramines that were responsible for their strong irritating activity. Redox potential measurement used as an auxiliary method substantially alleviates on-line technological monitoring of the efficiency of water decontamination at the critical control point during chlorination and, during ozonation, makes up the existing gap of the current SanPiN 2.1.2.1188-03.

[World Health Organization Guidelines for swimming pools and similar recreational water environments: Italian translation by the SItI Working Group "Enhancing health and physical activity"]

The Working Group "Enhancing Health and Physical Activity" of the Italian Society of Hygiene, Preventive Medicine and Public Health promoted the Italian translation of the WHO Guidelines for safe recreational waters, swimming pools and similar environments. The structure of the WHO document is described and the main chapters are summarised. References are included from Italian studies and data provided by the Working Group.

Development and validation of AIMFREE: Accessibility Instruments Measuring Fitness and Recreation Environments

PURPOSE

The purpose of this study was to develop and validate a series of 16 survey instruments measuring fitness and recreation accessibility, collectively referred to as AIMFREE (Accessibility Instruments Measuring Fitness and Recreation Environments). General domains of assessment included the built environment, equipment, programmes, policies, and training and behaviour.

METHODS

Fitness and recreation professionals (n=35) assessed fitness centres/swimming pools (n=35) in nine regions across the US. Rasch analysis was used to assess the psychometric properties of the instrument.

RESULTS

The AIMFREE evidenced adequate to good fit to the Rasch model and adequate to good internal consistency (r=0.70 - 0.90). Test-retest reliability ranged from 0.70 (entrance areas) to 0.97 (swimming pools). Analysis of differential item functioning indicated that item calibrations generally did not differ significantly between urban and suburban environments.

CONCLUSION

The AIMFREE instruments demonstrated adequate to good fit to the Rasch model with several of the subscales demonstrating well to excellent separation of facility accessibility.

Growth and evolution of a municipal pool safety and inspection program

The city of Plano Health Department swimming pool safety and inspection program has been growing and evolving since 1992. Currently, five environmental health specialists inspect 370 permitted commercial swimming pools. The environmental health specialists, who are all well trained and are Certified Pool Operators by the National Swimming Pool Foundation, inspect each facility twice during the summer season. The department considers quality training for both inspectors and operators a priority. Violation rates have been variable across the program, but improved operator training is proving successful in many areas. The program also plays a role in swimming pool construction by providing plan review services and construction inspections. Increased involvement in construction and design has significantly reduced problems and improved compliance with new pools. This has resulted in a higher level of service and swimmer safety. Additionally, a net drop in chemistry violations has been shown over the last three years. The department is constantly evaluating safety in public and semi-public pools in Plano in an effort to provide a maximum level of swimmer safety.

Association between swimming pool operator certification and reduced pool chemistry violations--Nebraska, 2005-2006

Previous studies have recommended mandatory education for all public pool operators, but substantiating data are limited. This study evaluates associations between pool operator certification and chemistry violations by using 2005-2006 Nebraska routine pool inspection reports. Training and certification for nonmunicipal pool operators are only required in two Nebraska counties. Free chlorine violations for nonmunicipal pool inspections were compared in counties with and without certified operator requirements. To control for water supply pH, inspections from nonmunicipal pools with shared-source water in two counties (one requiring certification) were compared for concurrent pH and free chlorine violations. Compared with locations that require certified operators, free chlorine violations and concurrent pH and free chlorine violations were twice as likely in locations without certification. As a result, pools without required operator certification might pose greater health risks. These results demonstrate the benefit of requiring pool operator certification to help prevent recreational water illnesses.

Childhood asthma and environmental exposures at swimming pools: state of the science and research recommendations

OBJECTIVES

Recent studies have explored the potential for swimming pool disinfection by-products (DBPs), which are respiratory irritants, to cause asthma in young children. Here we describe the state of the science on methods for understanding children's exposure to DBPs and biologics at swimming pools and associations with new-onset childhood asthma and recommend a research agenda to improve our understanding of this issue.

DATA SOURCES

A workshop was held in Leuven, Belgium, 21-23 August 2007, to evaluate the literature and to develop a research agenda to better understand children's exposures in the swimming pool environment and their potential associations with new-onset asthma. Participants, including clinicians, epidemiologists, exposure scientists, pool operations experts, and chemists, reviewed the literature, prepared background summaries, and held extensive discussions on the relevant published studies, knowledge of asthma characterization and exposures at swimming pools, and epidemiologic study designs.

SYNTHESIS

Childhood swimming and new-onset childhood asthma have clear implications for public health. If attendance at indoor pools increases risk of childhood asthma, then concerns are warranted and action is necessary. If there is no such relationship, these concerns could unnecessarily deter children from indoor swimming and/or compromise water disinfection.

CONCLUSIONS

Current evidence of an association between childhood swimming and new-onset asthma is suggestive but not conclusive. Important data gaps need to be filled, particularly in exposure assessment and characterization of asthma in the very young. Participants recommended that additional evaluations using a multidisciplinary approach are needed to determine whether a clear association exists.

Predictive indicators of the safety of swimming pool waters

Many outbreaks related to swimming pools could have been prevented or reduced if the pool had been well managed and effectively monitored. The aim of this study was to evaluate physicochemical and microbial parameters that can be proposed as an indicator for the safety of swimming pools. A total of 234 water samples, over a 10-month period in 2006-2007, were collected from indoor swimming pools in Isfahan. All water samples were analyzed for physicochemical and microbial parameters including temperature, pH, turbidity, conductivity, free chlorine, heterotrophic plate count (HPC), total (TC) and fecal coliforms (FC), fecal streptococci (FS) Staphylococcus aureus (Sa) and Pseudomonas aeruginosa (Pa). The highest isolation of microbial indicators was for total coliforms (38%) and the lowest for fecal streptococci (3%). The correlation analyses indicated that free chlorine concentration had a significant negative relationship with the heterotrophic bacteria population and total coliforms. Total coliforms presented a significant correlation with the other microbiological indicators. The results clearly showed that the hygienic quality of the swimming pools was dependent on the efficacy of disinfection. Thus, the free chlorine and pH were good operational indices for the quality control of swimming pools and must be maintained in the recommended range to ensure optimal disinfection. The results also showed that TC and HPC were reliable and practical indicators for routine quality surveillance and assessment of the efficiency of the disinfection process and safety of swimming pools.

[Surveillance of the sanitary conditions of a public swimming pool in the city of Palermo (Italy)]

In a previous study we evaluated the microbiological quality of water of seven pools in the city of Palermo through evaluation of bacterial indicators of faecal contamination and of protozoa (Giardia and Cryptosporidium). In this study we also searched for the presence of fungi in two swimming pools of a public swimming facility in the same city. Samples were collected from both pools, their filtration systems and floor surfaces of the facility. Chemical-physical and microbiological examination of water of the two pools have shown that quality of water depends on the concentration of residual free chlorine and on the number of bathers in the pool. The values of four microbiological parameters (bacterial load at 22 degrees C and 36 degrees C, presence of coagulase-negative Staphylococci and Pseudomonas spp.) increased with diminishing chlorine concentrations and with increasing number of pool users. Faecal bacteria, Giardia and Cryptosporidium were not found. On the other hand, various fungi were isolated from floor surfaces and pool water even in the presence of optimal chlorine concentrations. This study confirms the importance of regular maintenance of pool disinfection systems and suggests the need to search for other micro-organisms not included in the current legislation (Giardia, Cryptosporidium and fungi).

Chemical and microbial decontamination of pool water using activated potassium peroxymonosulfate

Potassium peroxymonosulfate activation leads to the formation of highly reactive species, mainly the sulfate radicals. Activated potassium peroxymonosulfate (from now on peroxymonosulfate) was tested against specific pollutants such as ammonium ion, creatinine, chlorinated creatinine products, arginine and Escherichia coli (E. coli), all constituents or derivatives of human discharges. The objective was to assess whether activated peroxymonosulfate can be a viable treatment reagent in recreational water applications. It was found that organic molecules such as creatinine, chlorinated creatinine products and arginine could be effectively treated with activated peroxymonosulfate. Ammonium ion was oxidized only by chlorine species and only in de-ionized water. Chlorine species were formed from the reaction of sulfate radicals with chloride ions. In pool water, the reaction of sulfate radicals with chloride ions and the subsequent ammonium ion oxidation were scavenged by the presence of bicarbonate ions. The Co/Peroxymonosulfate system was also shown to be an effective disinfection reagent, since 99.99% (4-log) kill of E. coli was achieved in 60 min of treatment. At the concentrations tested here, however, it is still not efficacious enough to qualify as an EPA-registered sanitizer for swimming pools (requires 6-log kill of E. coli, ATCC 11229, and Enterococcus faecium, ATCC 6569, in 30s).

Shipshape: sanitation inspections on cruise ships, 1990-2005, Vessel Sanitation Program, Centers for Disease Control and Prevention

In the course of a successful collaboration between the Centers for Disease Control and Prevention (CDC) and the cruise ship industry on reducing common-source outbreaks, CDC's Vessel Sanitation Program (VSP) has expanded its training, education, and cruise ship inspection programs. The study reported here evaluated 15 years of ship sanitation inspection data from the National Center for Environmental Health and assessed performance in specific sanitation categories from 1996 to 2005. During the period 1990-2005, scores from cruise ship environmental sanitation inspections steadily improved. The percentage of inspections with violations decreased among five of nine categories. Those five categories were Washing Facilities, Contact Surfaces, Facility Maintenance, Food Handling, and Communicable Disease Practices. Inspection violations increased proportionally in the categories of Swimming Pools and Water System Protection/Chart Recording. Overall continued good performance in most sanitation categories is likely attributable to on-site training during inspections, improvements in ship construction, and a switch from hot-holding temperatures to time limits as a public health control for foods on display.

[Hygienic standards of chemicals for water sterilization in the swimming pools]

The authors proposed a concept of making the hygienic standards for water disinfectants in the swimming pools, by substantiating their allowable residual concentrations (ARC), as well as criteria for evaluating the effectiveness and safety of swimming pool water disinfectants: a ratio of ARC to the optimum bactericidal concentration (if the ratio is less than 1; the agent is not recommended for use); a ratio of the maximum noneffective concentration of a local irritant action to the optimal bactericidal concentration of a disinfectant (if the ratio is < or =5; the agent is not permitted for use); a specific activity (agents that can cause allergenic and carcinogenic effects, as well as a mutagenic effect revealed on mammals or man are not permitted for use); the content of impurities in the disinfectant (when the agent is used in the dose equivalent to 3-5 optimal bactericidal concentrations; the water levels of impurities should be not more than 0.5 of the maximum permissible concentration. In accordance with the proposed procedure, ARC of BioPAH (polyhexamethyleneguanidine hydrochloride) has been estimated to be 5 mg/l. However, the agent may not be permitted for use in the swimming pools as it contains hazardous impurities.

Microbiological quality of indoor and outdoor swimming pools in Greece: investigation of the antibiotic resistance of the bacterial isolates

During 1997-2005, the microbiological quality and susceptibility of bacterial isolates of swimming pool waters were investigated. A total of 462 water samples were collected from three indoor swimming pools (a teaching pool, a competition public pool, a hydrotherapy pool) and two outdoor swimming pools (a hotel semi-public and a residential private pool) in Northwestern Greece. All water samples were analyzed for the presence of bacteria, protozoa and fungi and susceptibility tests were performed for the bacterial isolates. Sixty-seven percent of the examined water samples conformed to the microbiological standards and 32.9% exceeded at least one of the indicated limits. Out of 107 bacterial isolates, 38 (35.5%) resistant strains were detected. Multi-resistant Pseudomonas alcaligenes, Leuconostoc, and Staphylococcus aureus (isolated from the teaching pool), Staphylococcus wernerii, Chryseobacterium indologenes and Ochrobactrum anthropi (isolated from the competition pool), Pseudomonas aeruginosa, P. fluorescens, Aeromonas hydrophila, Enterobacter cloacae, Klebsiella pneumoniae and S. aureus (isolated from the hydrotherapy pool) and A. hydrophila (isolated from the hotel pool) were detected. The swimming pool with the poorest microbiological quality (THC 500 cfu/ml in 12.1% of the samples, P. aeruginosa counts 1500 cfu/100 ml in 6% of the samples) and the highest prevalence of multi-resistant isolates (73.6%) was the hydrotherapy pool. No Cryptosporidium or Giardia cysts and no Legionella, Mycobacteria and Salmonella were detected, but there were isolations of Candida albicans, Aspergillus spp., Mucor spp., Alternaria spp., Rhizopus spp., Trichophyton spp., and Penicillium spp.

[Hygienic risks in swimming pool: knowledge and behaviours of consumers of three structures in Crema, Parma and Naples]

The swimmers health's protection and the maintenance of good safety standards of structures can be guaranteed under observance of rules and the well management of the structures and activities. An anonymous questionnaire, with 38 items, was used in order to analyse and better understand the knowledge and behaviour of the users of three swimming pools in Crema, Naples and Parma. Socio-demographic features were similar in the three centres. One of the most important result was that the necessity of showers and foot-bath before entering the swimming pool is not well understood (77% and 78% respectively); caps and foot bath are, instead, almost always worn (98% and 97%). Knowledge on infection diseases transmitted by water is very poor, warts and mycosis being the best known. Sport structures are places where health and wellness can be affected. It is important to underline the role of behavioural rules as the use of showers, caps, and proper shoes. Authors recognize the swimming pool regulations as a valid tool for health promotion. It must be clear and easily understood and it has to be linked to a proper education pathway of all users and employees.

Sources of variability in levels and exposure to trihalomethanes

In the framework of a cohort study of pregnant women conducted in Brittany (France), we assessed the exposure to trihalomethanes (THM) during pregnancy in a subset by evaluating (1) potential sources of variability in household THM levels; (2) the between- and within-subject variability in THM levels; (3) THM levels in swimming pools; and (4) the role of water-related habits on total THM uptake. We visited 109 women from the ongoing cohort study at home for an interview and collection of tap water from October to December 2004. Forty-three of them were re-contacted to obtain a second tap water sample in April-May 2005. We designed a questionnaire to collect individual information on source and amount of drinking water, frequency of showering, bathing, and swimming pool attendance, and household characteristics. We obtained 282 THM measurements, 152 specifically for the study and 130 from a regulatory agency. Personal information and environmental data were combined using two methodologies (method 1 using regulatory data and method 2 using our THM measurements) with a different set of assumptions. We calculated ingestion, showering, bathing, and swimming pool THM uptakes and added up those uptakes to calculate total THM uptake. Average THM levels from our measurements in October, November-December, and April-May were 61.3, 45.1, and 54.5 microg/l, respectively. Geographical variability was low and characteristics of the household did not influence THM levels. Within-subject variability in THM levels was three times higher than between-subject variability. Average THM level in swimming pools was 80.4 microg/l. Average water consumption during pregnancy was 1.9l/day. The source of the household drinking water was 90% bottled, 8% municipal, and 2% from other sources. Forty-seven per cent attended swimming pools during pregnancy. Using method 1, the geometric mean of total THM uptake was 0.93 microg/day. Showering contributed 64%, swimming in pools 23%, bathing 12%, and drinking water 1% to the total THM uptake. In a setting with low geographical variability and limited environmental measurements, individual data is highly relevant to determine personal THM exposure and uptake. In a population that mainly drinks bottled water (e.g., pregnant women), individual THM uptakes are dominated by inhalation and dermal absorption during, showering, swimming in pools, and bathing.

Management of environmental health issues for the 2004 Athens Olympic Games: is enhanced integrated environmental health surveillance needed in every day routine operation?

Background

Management of environmental health issues is an integral part of public health systems. An active integrated environmental health surveillance and response system was developed for the Athens Olympics to monitor and prevent exposure to environmental hazards. The potential for permanent implementation of the program was examined.

Methods

The environmental health surveillance and response system included standardization, computerization and electronic transmission of data concerning environmental inspections of 17 site categories (restaurants, swimming pools etc) of public health interest, drinking and recreational water examinations and suggested corrective actions. The Olympic Planning Unit integrated and centrally managed data from 13 public health agencies, recommended, supervised and coordinated prompt corrective actions. Methods used to test the effectiveness of the program were the assessment of water quality test and inspection results trends over time using linear regression and epidemiological surveillance findings.

Results

Between January 2003 and September the 30th, 2004, 196 inspectors conducted 8562 inspections, collected 5024 water samples and recommended 17 027 corrective actions. In 10 cruise ships used as floating hotels inspectors conducted 10 full inspections, 2 re-inspections, and 27 follow-up inspections. Unsatisfactory inspection results (r = 0.44, p < 0.0001) and positive water quality tests (r = 0.39, p < 0.001) presented an overall decrease trend over time. In August, 2003, an outbreak of salmonellosis was linked to a hotel restaurant which accommodated athletes during a test event.

Conclusion

Lessons learned for future events include timely implementation and installation of communication processes, and rapid and coordinated response to unsatisfactory inspection results. Routine national programs need to adopt enhanced environmental health surveillance aimed at public health decision-making, but with a different perspective.