Germwarfare and Your Aquatic Facility.

The initial hysteria of an E. coli outbreak allegedly traced to a Georgia waterpark tot pool has slowly subsided. The questions raised by the outbreak, however, have not. How did the children get exposed to the fecal material in the pool? Doesn't chlorine quickly kill germs? Wasn't there any chlorine in the pool? Are they sure the infection came from the pool? Could this happen at my pool? In the months following the outbreak, I received many calls from concerned citizens regarding our fecal accident policy. I read articles from seemingly informed authorities, which only seemed to add to the public's hysteria. So how do we separate fact from frenzy and find a reasonable and safe way to handle fecal accidents without losing operating days and customers?

First of all, let's take a look at the germs in question. These four pesky pathogens are of the greatest concern to pool operators: Escherichia coli 0157:H7, or E. coli; Cryptosporidium parvum, a.k.a. Crypto; Giardia lamblia; and Pseudomonas auruginosa. There are more, but these seem to be seen more often in the newspapers. The most prominent in the news and hysteria department are E. coli and Crypto. Both of these are bad bugs that affect the intestinal tracts of their hosts, causing diarrhea, dehydration, and even death in some cases. Healthy people may fight off the disease after exposure without symptoms. However, the elderly, very young, and those suffering from an autoimmune deficiency may become very ill, develop complications, or die as a result of exposure. Normal chlorine levels in a swimming pool quickly kill E. coli. However, it may take three days to rid a properly chlorinated pool of Crypto.

Either infection may be spread by a patron putting something into his or her mouth that has been contaminated by the stool of an infected person or animal. At a swimming pool, that could be something eaten for lunch, unwashed hands, or more remotely the pool water.

If Crypto takes so long to die, why aren't there more Crypto infections? The truth is that very few people have the disease, and even fewer of those people are experiencing fecal releases in pools. The Centers for Disease Control and Prevention has claimed that at least 10 outbreaks of Crypto have been tied to swimming pools or waterparks since 1988.

The most noteworthy was a 1988 incident in Los Angeles. At least 44 people contracted Cryptosporidiosis (the actual condition caused by Cryptosporidiurn protozoa) after swimming at a high-school pool. This pool was high-use, low-volume (100,000 gallons), and one-third of the filter was not working. While this is true of many older pools, one question still remains: Why are more people not getting sick? The answer is that the introduction of infected material into swimming pools is very rare.

As concerned pool operators, we cannot ignore the danger these bad bugs present to our patrons; we also should not overreact and assume that every defecation in a pool is loaded with Crypto. Dumping a 500,000-gallon pool, chemically retreating and reheating the new water, and sterilizing the pool filters will kill the bad bugs -- if they were ever there in the first place. If we look at all the pools in the United States, count all the swimmer entries to those pools, and calculate all the people who have been infected by the aforementioned bacteria, we can see that the statistical probability of being infected is very remote. Natural-water swimming areas such as beaches may have legal levels of E. coli large enough to infect nearly 10 out of every 1,000 swimmers (CDC). Still, few reported infections from this organism come from swimming beaches.

So why the hysteria? Perhaps we suffer from too much information -- and not enough fact and actual application to the situation of pool operators. Published articles that advise dumping pools, sterilizing filters, and generally closing down facilities at any confirmed "pool stool" sighting are not considering the probability that someone will get sick.

Recently a pool in California had at least 30 confirmed "UFO" (unidentified floating object) sightings and five "possibles" in one three-month summer season. By faithfully following all of these recommendations, the pool would only have been open for two weeks. Did the aquatic staff place patrons in harm's way by not doing everything possible to sterilize the pool after discovering a foreign body? No. The truth is, at one part per million of chlorine, virtually 100 percent of the typical germs found in fecal material are killed within two seconds. At that kill rate, one would have to be extremely close to the "floater" to be infected. Without argument, the possibility of Crypto getting into your pool exists. But the probability of getting Crypto from your pool water is remote. If Crypto infections have been reported in your area, then more vigorous precautions and treatment may be necessary and, in fact, prudent.

Persons infected with E. cold, Crypto, or Giardia are very sick. They are weak, feel terrible, and can't risk getting far from the toilet without suffering the indignity of a fecal accident of the personal kind. Kids may venture from home to the pool, but adults will rarely stray from home when this ill.

It does not take the highly visible "goldfish" to warrant a fecal emergency. Fecal material is actually constantly introduced and unseen. Poor hygiene after a bowel movement is the primary culprit. What about parents who use a deck chair as a diaper-changing station. Is that chair disinfected between patron uses? Instead of washing his or her hands in the lavatory, this parent may simply "swish" them in the pool. Did he or she throw the diaper away, or is it under the chair? Also, kids are prone to poking their hands into their soiled diapers. Is staff trained to "apprehend" patrons practicing poor hygiene, or even monitor the deck diaper change? Just try stationing shower monitors in your dressing rooms to make sure that every nook and cranny has been sufficiently washed. How long would it take before molestation or harassment charges were filed? Many states require that pool operators enforce the shower rule, but this becomes such a public relations problem that shower enforcement is rare.

So what reasonable precautions and procedures can an aquatic manager take to reduce the probability of infection? First of all, develop a plan to prevent and handle any unauthorized deposits into the pool.

This plan should address the following points:

* Educate your pool staff. Create a written policy to address identification of the offensive material, its removal from the pool, and its sanitary disposal. At all times you should follow your state or local health codes -- even if they are a little "over the edge." Staff must know how to identify likely emitters (for example, infants in loose diapers). Once the material is removed, close the immediate area of the suspected emission. If you have an "adequate" sanitizer residual in the pool, wait to reopen for about 30 minutes. By this time, the chlorine will have had enough time to kill the normal germs in 100 stools.

* Educate your patrons. Place additional signage in the shower rooms and at your front desk. These signs should educate the public about the importance of good hygiene without putting them into a panic. The CDC has many recommendations for signs, but these four rules are the most important:

1. "If you have or have had diarrhea in the past two weeks, please do not use the pool."

2. "Shower your child and yourself before entering the pool."

3. "Swimmers who are not toilet-trained should wear a close-fitting swim diaper."

4. "Notify pool management if you or a family member develops a gastrointestinal illness that you think may have been related to a visit to the swimming pool."

* Soap showers are for everyone. It is necessary that all pool patrons take a hot soap shower and wash everywhere. The pre-swim baptism consisting of little more than a few pints of water just won't do it.

* Plastic pants are more than a fashion statement. You should require that toddlers wear tight-fitting plastic pants in an effort to keep the fruits of their efforts to themselves.

* Diaper changing is not a spectator sport. Have an actual diaper-changing station in your restrooms, with specific instructions to wash the "southern end" of your child before he or she re-enters the pool. Do not allow parents to change diapers on the deck. If the routine changing turns into a vigorous athletic event, you may have to disinfect the whole area. Parents may also just swish their hands off in the pool instead of washing in the lavatory.

* Sick people belong at home. Make a rule that people and children who have or have had diarrhea in the past two weeks stay out of the pool. If it causes someone to think, then it may be worth it.

* Do not let people drink pool water. This was actually a recommendation from the CDC. There is no way you can prevent inadvertent gulps, but you must stop the intentional ones.

* Use a reliable chemical automation system to maintain disinfectant levels in the pool. Both chlorine and pH levels are important to maintain constant and effective bug kill.

* Map your pool. Not all pools circulate water evenly. While one pool area may test at 1.0 parts per million (ppm) of chlorine, another area may simultaneously test at a significantly lower level. If there are some areas that chronically collect dirt or grow algae, you can suspect a lack or absence of chlorine. This can be corrected by redistributing water circulation. If that is not possible, then try increasing the average level in the pool. If you normally operate at 1.0 ppm, increase it to 2.0 ppm so that poorly circulated areas receive more. If you use a chlorine stabilizer in an outdoor pool, then you will need to raise your free chlorine residual as high as legally possible. A stabilizer -- cyanuric acid -- prevents the degradation of chlorine to sunlight, and reduces the time it takes chlorine to kill germs. Keeping your chlorine concentration higher will help reduce this effect. The level of acidity also affects the ability of chlorine to kill germs. In conjunction with your local health codes, try to maintain the pH in your pools at 7.4 or lower. Chlorine's form in water -- hypochlorous acid -- ionizes at higher pH levels. Ionized hypochlorous acid will slow the time it takes to kill germs.

* Maintain your facility. Clean and disinfect your dressing rooms and toilets daily. Make sure that filters and other mechanical equipment are in working order and on a regular preventive maintenance schedule. Do not backwash your filters unless necessary. Dirty filters clean better than clean filters because dirt catches dirt. Only backwash your filter when water clarity starts to suffer, or when water flow falls below your local health code standards.

* Train your operators through a nationally recognized pool-operator course, The National Recreation and Park Association offers its Aquatic Facility Operator course at sites nationwide. Call [phone] for dates and locations.

Obviously, there are many ways to reduce the risk of someone getting sick from a "bottom beastie" at your aquatic facility. Many states are revising their health codes to either accommodate or dispel public hysteria. For example, Oregon is considering an enlightened policy that takes into consideration the probability, rather than the possibility, of infections. The rest of us should rely on common sense and a few reasonable rules and procedures. By doing this, you will reduce risks, your pools will stay open, and your patrons will stay healthy.

References

Centers for Disease Control and Prevention. June 1995. Cryptosporidiosis Fact Sheet.

Centers of Disease Control and Prevention. Cryptosporidium and Cryptosporidiosis: Information for Swimming Pool Operators.

Professional Pool Operators of America. Summer 1998. "The Dreaded E. coil bacterium." The Pumproom Press.

Sorvillo, F.J. "Swimming-Associated Cryposporidiosis-Los Angeles County." Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. May 25, 1990.