Is swimming in recreational water associated with the occurrence of respiratory illness? A systematic review and meta-analysis

Physicochemical and bacteriological quality of swimming pools water in Kombolcha Town, Northeastern Ethiopia

Introduction

The use of swimming pool water for recreation, rehabilitation, and athletics is widespread around the world, especially in large Cities and Towns. However, poorly managed swimming pool water can facilitate the spread of illnesses connected to recreational water. Despite this, there is no evidence on quality of swimming pools water in Kombolcha Town. Therefore, this study was aimed to evaluate the physicochemical and bacteriological quality of swimming pools water in Kombolcha Town.

Methods

A laboratory-based cross-sectional study was conducted from February to April, 2021 in Kombolcha Town. A total of 90 water samples were collected from the three outdoor swimming pools. The collected data of both physicochemical and bacteriological parameters were entered into Microsoft Excel 2010 and analyzed using SPSS version 25.0. One-way ANOVA was used to test whether there were statistically significant differences between different swimming pools. The level of significance was declared at a p-value of <0.05.

Results

In this study, out of all the pool water samples that were examined, 37.8% had pH values between 7.2 and 7.8, 36.7% had temperatures between 21°C and 32°C, and 26.7% had turbidity values that were within the WHO standard. Furthermore, only 16.7% of the pool water samples showed residual chlorine levels of 2-3 mg/L. In addition, only 27.8, 35.6, and 32.2% of the samples, respectively, met the WHO criterion for total coliform, fecal coliform, and heterotrophic plate count.

Conclusion

The result indicates that most pool water samples did not fulfill both the physicochemical and bacteriological quality of the WHO standard limit for swimming pools. Thus, it is crucial to clean and regularly check the pool water, apply pool safety requirements, and raise pool user's awareness about the danger of pool water pollution through training.

Inactivation of SARS-CoV-2 in Water by Chlorination

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is present in both respiratory secretions and feces, creating its potential for transmission by swimming pools. Recreational water activity is known to be at increased risk of respiratory infections and respiratory viruses have caused been detected and have caused outbreaks in swimming pools. However, little is known regarding the chlorine inactivation of SARS-CoV-2 in water typical of swimming pools in the USA. In this study, the inactivation of SARS-CoV-2 Isolate hCoV-19/USA-WA1/2020 was observed in water by chlorination. All experiments were conducted within a BSL-3 laboratory at room temperature. Our results show that the virus was reduced by 3.5 log (> 99.9%) after 30 s of 2.05-mg/L free chlorine contact and greater than 4.17 log (limit of detection) (> 99.99%) within 2 min.

Health-related behaviors and associated factors among swimming pool users in Kombolcha Town, Northeastern Ethiopia

Objective

Unhealthy behaviors during swimming exposes at risk of recreational water-associated diseases. The swimming pool users are the high-risk group for getting and transmitting the diseases. Thus, conducting a study on swimming pool users' health-related behaviors is crucial to prevent the transmission of recreational water-associated diseases.

Methods

This cross-sectional study was employed among 140 randomly selected swimming pool users from April 1st to 30th, 2021 in Kombolcha Town. Data were collected using an interviewer-administered questionnaire and an on-the-spot-observational checklist. The collected data were entered to EpiData version 4.6 and exported to SPSS version 25 for data cleaning and analysis. Determinants of health-related behaviors were identified by using a multivariable logistic regression model at a p-value < 0.05.

Results

The overall good health-related behavior among swimming pool users was 41.4% (95% CI: 33.6-49.3). Out of the total 140 swimming pool users, 55% (95% CI: 46.4-62.9) had good knowledge about health risks during swimming. Good knowledge about health risks during swimming (AOR = 9.64; 95% CI: 3.14-29.61), educational status of college or above (AOR = 6.52; 95% CI: 1.76-24.10) and age being > 28 years (AOR = 6.49; 95% CI: 2.34-18) were factors significantly associated with good health-related behaviors.

Conclusion

The finding of the study showed that the majority of the swimming pool users had poor health-related behaviors. Thus, Kombolcha Town Health Bureau and swimming pool managers should give attention to this population to enhance health-related behaviors through addressing the significant predictors.

Health risks to children from exposure to fecally-contaminated recreational water

Background

Children may be at higher risk for swimming-associated illness following exposure to fecally-contaminated recreational waters. We analyzed a pooled data set of over 80,000 beachgoers from 13 beach sites across the United States to compare risks associated with the fecal indicator bacteria Enterococcus spp. (measured by colony forming units, CFU and quantitative polymerase chain reaction cell equivalents, qPCR CE) for different age groups across different exposures, sites and health endpoints.

Methods

Sites were categorized according to the predominant type of fecal contamination (human or non-human). Swimming exposures of varying intensity were considered according to degree of contact and time spent in the water. Health endpoints included gastrointestinal and respiratory symptoms and skin rashes. Logistic regression models were used to analyze the risk of illness as a function of fecal contamination in water as measured by Enterococcus spp. among the exposed groups. Non-swimmers (those who did not enter the water) were excluded from the models to reduce bias and facilitate comparison across groups.

Results

Gastrointestinal symptoms were the most sensitive health endpoint and strongest associations were observed with Enterococcus qPCR CE at sites impacted by human fecal contamination. Under several exposure scenarios, associations between illness and Enterococcus spp. levels were significantly higher among children compared to adolescents and adults. Respiratory symptoms were also associated with Enterococcus spp. exposures among young children at sites affected by human fecal sources, although small sample sizes resulted in imprecise estimates for these associations.

Conclusion

Under many exposure scenarios, children were at higher risk of illness associated with exposure to fecal contamination as measured by the indicator bacteria Enterococcus spp. The source of fecal contamination and the intensity of swimming exposure were also important factors affecting the association between Enterococcus spp. and swimming-associated illness.

Climate Change Impacts on Microbiota in Beach Sand and Water: Looking Ahead

Beach sand and water have both shown relevance for human health and their microbiology have been the subjects of study for decades. Recently, the World Health Organization recommended that recreational beach sands be added to the matrices monitored for enterococci and Fungi. Global climate change is affecting beach microbial contamination, via changes to conditions like water temperature, sea level, precipitation, and waves. In addition, the world is changing, and humans travel and relocate, often carrying endemic allochthonous microbiota. Coastal areas are amongst the most frequent relocation choices, especially in regions where desertification is taking place. A warmer future will likely require looking beyond the use of traditional water quality indicators to protect human health, in order to guarantee that waterways are safe to use for bathing and recreation. Finally, since sand is a complex matrix, an alternative set of microbial standards is necessary to guarantee that the health of beach users is protected from both sand and water contaminants. We need to plan for the future safer use of beaches by adapting regulations to a climate-changing world.

Evaluation of recreational risks due to exposure of antibiotic-resistance bacteria from environmental water: A proposed framework

This research provides a framework for the human health risk assessment due to exposure of AR (antibiotic resistance) E. coli from recreational water (swimming activity). Literature-based epidemiological studies were used for f-value formulation (i.e., AR E. coli/total number of E. coli isolates) and the theoretical calculation of AR and non-AR E. coli concentrations. Risk was estimated using calculated values by considering four different dose-response (D-R) scenarios with known characteristics due to current lack of availability of D-R for AR bacteria. f-values ranged between 0.14 and 0.59 and the order of calculated theoretical values of maximum AR E. coli are as follows: ampicillin or amoxicillin (38 CFU/dip) > co-trimoxazole (19 CFU/dip) ~ tetracycline (18 CFU/dip) > ceftriaxone or cefotaxime or ceftazidime (10 CFU/dip) ~ ciprofloxacin or ofloxacin (9 CFU/dip). The risk of infection was considerably high for theoretical calculated concentration values regardless of the chosen D-R model (annual risk of infection (95th percentile) = 1, Spearman's rank correlation coefficient = -0.06 to 0.94), under the conditions studied. Further, AR levels of human gastrointestinal-tract were determined using literature-reported data in stool samples and indicated that the resistance level was very high in healthy human (range: 3.7 × 10⁷-8.4 × 10⁷ CFU/g of wet lumen content). The maximum allowable concentration values for AR E. coli and non-ARB (0.0075 CFU/dip and 2.56 CFU/dip) were found to be smaller than the USEPA recreational water quality guidelines (≤126 CFU/100 mL), which can help the USEPA and other regulatory bodies in revisiting the current guidelines. So based on the noted results, we can conclude that the maintenance of inventory of actual measured concentration of ARB in the recreational water sites is needed to prevent unwanted complication related to the treatment of infectious sustained by resistant microbes.

Evaluating health risks associated with exposure to ambient surface waters during recreational activities: A systematic review and meta-analysis

Recreational water quality guidelines protect the public from health risks associated with water recreation by helping to prevent unacceptable concentrations of pathogenic organisms in ambient water. However, illness risk is associated with both the concentration of pathogens in the water and the degree of contact with those pathogens. Different recreational activities can result in different levels of contact with ambient water containing water-borne pathogens. We conducted a systematic literature review and meta-analysis to evaluate risks of illness associated with different recreational activities and different levels of contact to ambient surface waters. We screened 8,618 potentially relevant studies for quantitative measures of risk using inclusion/exclusion criteria established in advance. We categorized recreational activities as swimming, sports-related contact, minimal contact, and sand contact. We combined relative risks using a random effects meta-analysis for adverse health outcome categories representing gastrointestinal illness, respiratory illness, skin, eye, ear, nose, throat, and cold/flu illness. We identified 92 studies meeting our inclusion criteria. Pooled risk estimates indicate significant elevation of gastrointestinal illness with the recreational activity categories swimming (2.19, 95% CI: 1.82, 2.63) and sports-related contact (2.69, 95% CI: 1.04, 6.92), and nonsignificant elevation of gastrointestinal illness with minimal contact (1.27, 95% CI: 0.74, 2.16). We also found a significant elevation of respiratory illness with swimming (1.78, 95% CI: 1.38, 2.29) and sports-related contact (1.49, 95% CI: 1.00, 2.24), and no elevation of respiratory illness with minimal contact (0.90, 95% CI: 0.71, 1.14). This study suggests that exposures associated with different types of recreational activities are important characteristics of the exposure pathway when assessing illness risk associated with recreation in ambient surface waters.

The potential human exposure to antibiotic resistant-Escherichia coli through recreational water

It is important that bathing water sites are free as possible from antibiotic resistant bacteria (ARB) to prevent the spread of difficult to treat infections throughout the population. This study examines the possible human exposure to antibiotic resistant Escherichia coli (AR-E. coli) through recreational activities at two different bathing water sites located near wastewater treatment plants (WWTPs). A quantitative risk assessment model was created to model the pathway of the AR-E. coli from the WWTPs effluent water through to the bathing water sites. Both sampling data and data from scientific literature were used. The main steps considered for the model were: the dilution and decay of the AR-E. coli from the WWTPs effluent water into the river; the dilution of the river into the bathing water sites and the human exposure to AR-E. coli through recreational activities at the bathing water sites (as a result of water ingestion). The results show the mean predicted human exposure levels ranged between 0.45 and 345.09 cfu/100 ml. A back calculation method determined that in accordance with the European Bathing Water Directive (2006/7/EC) (BWD) to be considered "poor" water quality, the concentration of AR-E. coli in WWTP effluent water would need to exceed 2.45 log cfu/ml at site 1 and exceed 2.71 log cfu/ml at site 2. This study provides valuable information for regulatory bodies and policy makers on the possible human exposure levels to AR-E. coli and the maximum permissible concentrations in WWTP effluent water to ensure compliance with relevant bathing water legislation.

Illnesses Associated with Freshwater Recreation During International Travel

PURPOSE OF REVIEW

International travel, adventure travel, and eco-tourism are increasing over the past few decades. This review aims to summarize the spectrum of infections associated with recreational freshwater activities and international travel.

RECENT FINDINGS

Recreational water activities can be associated with a wide range of infections. Acute febrile illnesses due to leptospirosis and schistosomiasis are not uncommon in travelers following extensive freshwater exposure. Aeromonas and other water-associated pathogens are important to consider in a traveler presenting with a skin and soft tissue infection. Recreational water activities are often associated with diarrheal illnesses, especially in children, and the range of enteric pathogens includes bacterial pathogens such as Escherichia coli O157:H7 and Shigella species and the protozoan parasites Cryptosporidium and Giardia duodenalis. Infections due to free-living amebas though rare can lead to fulminant central nervous system infections. A diverse range of infections may be associated with freshwater exposure, and it is important that these entities are considered in a returning traveler presenting with an acute illness.