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Preventive medicine oversight of splash pads on military installations.

For many years, splash pads have been constructed all over the world and are growing in popularity in the Unites States as a fun, economical way to entertain children and adults. There are an estimated 1,200 water parks in North America and about 720 in other countries around the world. In North America alone, water park attendance for 2012 was estimated to be approximately 85 million people, with an anticipated annual attendance growth rate of 3% to 5%. (1)

A splash pad is a recreational play structure that sprays treated or recycled water above the ground and is independently operated from another recreational water facility such as a pool. (2) Splash pads are also referred to as recreational spray parks, spraygrounds, spray pads, splash pads, spray pools, water parks, splash deck, interactive fountains, and wet decks (Figure 1).

MEDICAL CONCERNS

A splash pads features equipment that is designed to spray or splash patrons with water that then flows into a drain and is either filtered, disinfected, and recirculated through the spray feature or discharged into a wastewater system. A major advantage inherent in the design of splash pads is the elimination of standing water, which significantly reduces the risk of drowning. In the United States, drowning is the

number one cause of injury related death in children aged 1 to 4 years. (3)

Despite the very low risk of drowning and seemingly benign nature of these parks, there remains a very real public health risk from bacteriological infections. Splash pads have the potential to become a breeding ground for communicable diseases due to 3 problems: poorly or inadequately disinfected water sources, poorly or inadequately disinfected skin contact surfaces, and poorly designed and engineered park structures.

Since 1978, the Centers for Disease Control and Prevention (CDC), the US Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have maintained the Waterborne Disease and Outbreak Surveillance System (WBDOSS) for the collection of waterborne disease outbreak (WBDO) information associated with recreational water activities. When a WBDO is suspected, the state and local public health departments are expected to investigate it and voluntarily provide this data to the CDC for inclusion in the WBDOSS. (1)

Outbreaks at splash pads are the result of nonhygienic behaviors which contaminate the surrounding water. Patrons ingest the contaminated water and illness can ensue if the infective dose is high enough. Common nonhygienic behaviors include exposing buttocks to splash features, drinking water directly from a splash feature, not showering prior to using the splash pad, and allowing diapered children to sit in the water puddles that other children then intentionally or inadvertently ingest. (4)

From 1995 to 2004, exposure to recreational water in the United States resulted in more than 255 WBDOs, 18,500 illnesses, and 24 deaths. Seventy-six of the 255 WBDOs were linked to treated water venues (pools, spas, hot tubs), with cryptosporidiosis being responsible for 61.8% of the illnesses. (5) During this same time period, there were 6 outbreaks linked to recreational use of splash pads. Shigella infection resulted in 3 of the outbreaks, Cryptosporidium caused 2 outbreaks, and a coinfection of both Cryptosporidium and Shigella was the cause of one outbreak.

Data collected from the WBDOSS from 2005 to 2006 indicated a total of 78 WBDOs, resulting in 4,412 illnesses, 116 hospitalizations, and 5 deaths. Three-quarters of the outbreaks (58 of the 78) occurred at treated water venues. Gastroenteritis was associated with 48 outbreaks and accounted for 4,015 of the 4,412 total reported illnesses. Of the 48 gastrointestinal outbreaks, Cryptosporidium was associated with 31 outbreaks, and all but 2 of these outbreaks were related to treated water. (1)

In 2005, the state of New York reported a massive outbreak associated with the use of splash pads. (6) This event resulted in more than 3,000 people reporting as ill from their exposure to the water fountain and at least 425 confirmed cases of Cryptosporidium hominis. Although the interactive fountain water was filtered and chlorinated, it was determined that the residual chlorine level was inadequate to inactivate Cryptosporidium in the water holding tanks. This outbreak likely occurred as a result of fecal contamination of the water by an infected individual.

In 2006, an outbreak of gastroenteritis was epidemiologically linked to a splash pad in Orange County, Florida. (5) Forty-nine individuals became ill from infections caused by Cryptosporidium (9 cases), and Giardia (38 cases). Two individuals were found to have a coinfection with both Cryptosporidium and Giardia. Multiple breaches of proper sanitation which resulted in several contamination incidents were identified. The cause of the outbreak could not be determined conclusively, but is presumed to have been from asymptomatic carrier(s).

In 2007, an outbreak of cryptosporidiosis occurred from a municipal splash pad in Idaho, sickening 50 people. (7) Samples from the splash feature's sand filters and nearby drinking water fountains identified C hominis in both water sources. The initial cause of this outbreak was assumed to be from an ill patron that frequented the park and the subsequent illnesses were due to the ingestion of the fecally contaminated splash features and drinking water. It was also determined that the 2 drinking water fountains that shared a water line with the splash pad had faulty backflow prevention devices that may have led to the contamination of the drinking water and further contributed to the number of sick people.

From 2009 and 2010, the WBDOSS identified 81 recreational water-associated disease outbreaks from 28 states and Puerto Rico. These outbreaks resulted in more than 1,326 illnesses and 62 hospitalizations. Of the 81 total outbreaks, there were 57 outbreaks associated with treated recreational water venues and 24 associated with untreated recreational water venues (lakes, oceans). Of the 57 treated water recreational water venues, 24 were caused by Cryptosporidium. (8) Large outbreaks are more frequently seen in the summer months and are usually due to problems maintaining proper water quality, structural design, improper usage, and inadequate facility maintenance. (1)

These examples demonstrate why Cryptosporidium has become the leading concern for outbreaks of gastrointestinal illness associated with disinfected recreational water venues (6) (Figure 2). The number of confirmed cryptosporidiosis cases each year in the United States is approximately 748,000, with an estimated annual health care cost of $45.8 million. (8)

The features of Cryptosporidium that make it so menacing are its high resistance to normal water disinfection concentrations, its small size, its low infective dose, the high number of oocysts that are shed, and the extended duration of time that they can be shed. (8) Shedding of the parasites begins at the onset of symptoms and may continue for weeks after the illness stops. Infection spreads by ingestion of the parasite. The incubation period averages 2 to 10 days and the illness usually lasts 1 to 2 weeks. Although an infection can be asymptomatic (no symptoms), typical signs and symptoms of infection are stomach cramps and pain, dehydration, nausea, vomiting, fever, weight loss, headache, joint pain, and profuse diarrhea. Young children, pregnant women, and individuals who are immune deficient have a higher chance of contracting cryptosporidiosis and may suffer more severe symptoms. (8)

MILITARY REGULATIONS AND GUIDANCE

Technical Bulletin MED 5752 governs splash pads on all military installations. However, it only regulates splash pads designed to recirculate water. In addition, TB MED 575 does not include guidance specifying who on an installation has operation and maintenance oversight of splash pads. In response to these shortcomings, the document is currently being updated by the US Army Public Health Command. The proposed updates to TB MED 575 refer to the Model Aquatic Health Code (MAHC) (3) for information on design, construction, operation, and maintenance of recreational facilities not addressed in the current version.

The MAHC was developed by CDC through a national partnership approach as a guidance document for state and local agencies to use as a model of public health standards for swimming pools and other aquatic facilities. However, like TB MED 575, the MAHC does not address nonrecirculating splash pads. The CDC elected to remove language regarding nonrecirculating splash pads from the draft MAHC. Based on comments received from the public, primarily through local governments, the general concern with nonrecirculating splash pads appeared to be economic. (3)

In addition to TB MED 575 and the MACH, military installations must comply with Executive Order 131239 when installing splash pads. Under that order, military installations will reduce water consumption and energy use throughout the installation to reach goals established by the installation. Under the Army's Net Zero initiative, Army installations are focused on limiting use of freshwater resources and returning water to the same watershed in an effort to preserve the ground and surface water resources. (10)

Generally, most designs for military installation buildings and facilities are based on Department of Defense (DoD) Unified Facilities Criteria:

Unified Facilities Criteria documents provide planning, design, construction, sustainment, restoration, and modernization criteria. (11)

Unfortunately, design, operation, and maintenance documents containing specific guidance have not been created for recirculating and nonrecirculating splash pads. (11)

DESIGN RECOMMENDATIONS

In order to limit the occurrence of waterborne illnesses and ensure the health and safety of Soldiers and families, military installations should follow the following design recommendations:

* Use the best available water source.

* Use and maintain the best available technology for water treatment.

* Consider energy and water sustainability measures.

To ensure installations are using the best design recommendations, installation medical treatment facility (MTF) preventive medicine (PM) personnel should have oversight of the design of the splash pads.

A study by de Man et al (12) found that higher concentrations of E coli have been measured at splash parks using rainwater or surface water as compared to sites using potable water, independent of the routine inspection intervals and disinfection method used. To mitigate such risk, Army installations should use potable water. Any other alternative sources of water use would be subject to applicable state law.

Untreated or inadequately treated water at splash parks may allow waterborne pathogenic organisms to survive and infect users. Best available technology water treatment can remove and/or destroy these organisms. For example, while cryptosporidium cysts are resistant to chlorine, ultraviolet (UV) is an effective best available technology. Recirculating splash pads should have treatment that includes pH adjustment, filtration (sand or cartridge), UV, and chlorination. Water treatment systems should be Underwriter Laboratories Listed and incorporate chemicals listed by NSF International (NSF)/American National Standards Institute (ANSI) Standard 60, and NSF/ANSI Standard 61 components or equipment in contact with potable water. (13,14) Nonrecirculating facilities should consider booster chlorination when the background level of free available chlorine from the public water system is not to recreational water standards. Higher levels of disinfectant will sanitize the splash pad which is often used interactively by the youngest, highest at-risk population. Highly chlorinated water may require dechlorination before discharge to sanitary sewers or to a stormwater detention ponds in accordance with local and/or state governing authorities. Not properly maintaining or using water treatment equipment in accordance with standard or standing operating procedures and/or manufacturer's specifications can result in waterborne illness outbreaks, such as the outbreaks in New York in 200515 and Idaho in 2007. (7)

Health considerations and safety practices must be incorporated into the design during planning of a splash pad on an installation. To that end, it is important to seek advice from representatives of the installation PM staff. When feasible, planners will also include morale, welfare, and recreation representatives during concept discussions and planning charrettes. In addition to ensuring that splash pad designs take into account health and safety concerns, installation planners should consider energy and water conservation measures. (16)

In accordance with multiple Army requirements, MTF PM personnel provide technical assistance and support on the requirements and methods of water conservation. (17) Recirculating systems use more energy at the facility (for booster pumping), but conserve more water overall than one-use, pass-through potable water splash parks. They also eliminate the extra energy cost of supplying more water to a nonrecirculating system. Variable frequency drive pumps are typically more energy efficient than standard pumps and should be included as a design element, even though the initial cost may be higher. Also, instead of dumping filter backwash and underground recycle water from recirculating systems, the installation could further conserve overall water use by collecting, storing, and pumping such water to irrigation systems. Some states have reuse standards which must be satisfied before reclaimed water can be used. Overall, when possible, all splash pads should be recirculating to conserve water in accordance with federal executive orders and water conservation mandates of DoD and the Department of the Army.

Best Management Practice Recommendations

After design and construction, military installations should properly operate and maintain the facility, conduct baseline audits and routine inspections, and perform quality assurance monitoring to ensure Soldiers and families continue to enjoy splash pads without risk of illness. The installation MTF PM personnel should continue to have oversight on splash pads after construction to ensure such best management practices are employed and health risks are minimized.

The health and safety of children using splash pads depends largely on the operation, maintenance, and inspection of the facility. It is important that trained personnel such as lifeguards and pool operators who are responsible for the water play areas understand their role in protecting child health and safety. The personnel responsible for the splash pads should be trained to conduct inspections and how to handle contamination by bodily fluids, especially blood, excrement, and vomitus. Preventive medicine personnel should assess environmental and public health planning considerations, including but not limited to capacity (number of children allowed per square foot), daily water use, chemical requirements, seating, shade, drinking fountains, restroom and diaper changing access, foot and body showers, signage, trash receptacles, and safety and security concerns.

It is important that all installation organizations involved in oversight of splash pads, including but not limited to the directorate of public works; installation safety office; morale, welfare, and recreation; installation housing; and MTF PM personnel, have a clear understanding of inspection and maintenance program procedures and requirements, including child safety requirements in the outdoor play area. Water quality monitoring and maintenance of water treatment equipment is essential. Without clear guidance and current regulations, installations should follow the same procedures for sanitary control and operation of other recreational facilities outlined in Army Regulation 420-1,ls Technical Manual 5-662, (19) and Technical Bulletin MED 5752

Unfortunately, splash pads are not often inspected by state or local health authorities or MTF PM personnel. An inspection program is necessary to identify hazards and ensure deficiencies are corrected. The MTF personnel should perform preopening, annual, baseline, and routine sanitary inspections on all splash pads, recirculating and nonrecirculating, located on the installation, whether or not the state or local health authorities perform inspections. Nonrecirculated pools are typically unregulated and therefore not included in any sanitary inspection. They are also more likely to be operated by untrained personnel. Although risk for illness appears to be greatest at recirculated treated systems, safety and health issues could quickly become a rapidly escalating public health problem if personnel operating nonrecirculated splash parks do not handle incidents of animal or human bodily fluid contamination appropriately. Therefore, sanitary inspections should also include nonrecirculating splash parks. Further, the draft update to Technical Bulletin MED 5752 assigns to MTF PM the responsibility to ensure state and/or local public health jurisdictions are aware of and have access to privately owned water recreational facilities and/or public natural swim areas. It should be reemphasized that state and local health authorities do not always come onto military installations to conduct these inspections, making it even more important that MTF PM personnel conduct the sanitary inspections on a regular basis.

Children will inadvertently or intentionally drink water emitted from water features at a splash pad. Water quality records should be regularly reviewed by MTF PM who should also perform quality assurance sampling representative of the quality of water coming from the water features, including pH, free available chlorine, presence/ absence of coliform, and heterotrophic plate count. Particularly in the case of recirculating systems, heterotrophic plate count monitoring can be used as a tool to optimize treatment and ensure water use efficiency.

Army regulations and guidance are currently available or being updated to address recirculating splash pads. However, there is still no regulation or guidance that addresses nonrecirculating splash pads. While nonrecirculating splash pads may inherently be less of a risk for contamination, there is still a risk of contamination because individuals responsible for the facility may be untrained in sanitation practices when a contamination event occurs (ie, blood, fecal). Furthermore, nonrecirculating splash pads, even if less costly to maintain, are not in compliance with Federal, DoD, and Department of the Army mandates to conserve water. To ensure installations are properly maintaining the correct operations and maintenance of already existing recirculating and nonrecirculating splash pads, there must be clear regulation and guidance standards. The MTF PM personnel should be involved with the installation planners on the design of all splash pads and continue to maintain oversight of the splash pads during operations to ensure the health and safety of Soldiers and their families.

REFERENCES

(1.) Yoder JS, Hlavsa MC, Craun GF, et al. Surveillance for waterborne disease and outbreaks associated with recreational water use and other aquatic facility-associated health events-United States, 20052006. MMWR Surveill Summ. 2008; 57(9):1-29. Available at: http://www.cdc.gov/mmwr/preview/ mmwrhtml/ss5709a1.htm. Accessed 11/18/2014.

(2.) Technical Bulletin Medical 575: Occupational and Environmental Health Recreational Water Facilities. Washington, DC: US Dept of the Army; 1993.

(3.) Centers for Disease Control and Prevention. Model Aquatic Health Code [internet]. August 29, 2014. Available at: http://www.cdc.gov/healthywater/ swimming/pools/mahc/structure-content/index. html. Accessed November 18, 2014.

(4.) Nett RJ, Toblin R, Sheehan A, Huang WT, Baugh man A, Carter K. Nonhygienic behavior, knowledge, and attitudes among interactive splash park visitors. J Environ Health, 2010; 73(4):8-14.

(5.) Eisenstein L, Bodager D, Ginzl D. Outbreak of giardiasis and cryptosporidiosis associated with a neighborhood interactive water fountain--Florida, 2006. J Environ Health. 2008; 71(3):18-22.

(6.) Yoder JS, Beach MJ. Cryptosporidiosis surveillance-United States, 2003-2005. MMWR Surveill Summ. 2007; 56(7):1-10. Available at: http://www. cdc.gov/mmwr/preview/mmwrhtml/ss5607a1.htm. Accessed November 18, 2014.

(7.) Centers for Disease Control and Prevention. Outbreak of cryptosporidiosis associated with a splash park--Idaho, 2007. MMWR Morb Mortal Wkly Rep. 2009; 58(22);615-618.

(8.) Yoder JS, Wallace RM, Collier SA, Beach MJ, Hlavsa MC. Cryptosporidiosis surveillance-United States, 2009-2010. MMWR Morb Mortal Wkly Rep. 2012; 61(NSS05):1-12.

(9.) Executive Order 13123: Greening the Government through Efficient Energy Management, 64 Federal Register 109 (1999). Available at: http://www.gpo. gov/fdsys/pkg/FR-1999-06-08/pdf/99-14633.pdf. Accessed August 27, 2014.

(10.) US Department of the Army. Net Zero: A Force Multiplier [internet]. December 15, 2010. Available at: http://www.asaie.army.mil/Public/IE/netzero_ info.html. Accessed June 10, 2014.

(11.) National Institute of Building Sciences. Whole Building Design Guide [internet]. 2014. Available at: http://www.wbdg.org/ccb/browse_cat.php?c=4. Accessed September 22, 2014.

(12.) de Man H, Leenen EJ, van Knapen F, de Roda Husman AM. Risk factors and monitoring for water quality to determine best management practices for splash parks. J Water Health. 2014; 12(3):399-403.

(13.) NSF/ANSI Standard 60. NSF Website. 2014. Available at: http://www.nsf.org/services/by-industry/ water-wastewater/water-treatment-chemicals/nsf-ansi-standard-60/. Accessed September 10, 2014.

(14.) NSF/ANSI Standard 61. NSF Website. 2014. Available at: http://www.nsf.org/services/by-industry/ water-wastewater/municipal-water-treatment/nsf-ansi-standard-61/. Accessed September 10, 2014.

(15.) Centers for Disease Control and Prevention. Water Play Areas & Interactive Fountains [internet]. 20013. Available at: http://www.cdc.gov/healthy water/swimming/pools/water-play-areas-interac tive-fountains.html#one. Accessed September 22, 2014.

(16.) United Facilities Criteria (UFC): Installation Master Planning. Washington, DC: US Dept of Defense; 2012. UFC 2-100-01. Available at: http:// wbdg.org/ccb/DoD/UFC/ufc_2_100_01.pdf. Accessed September 10, 2014.

(17.) Department of the Army Pamphlet 40-11: Preventive Medicine. Washington, DC: US Dept of the Army; 2009. Available at: http://www.apd.army. mil/pdffiles/p40_11.pdf. Accessed September 10, 2014.

(18.) Army Regulation 420-1: Facilities Engineering: Army Facilities Management. Washington, DC: US Dept of the Army; 2008 (revised 2012):264. Available at: http://www.apd.army.mil/pdffiles/r420_1. pdf. Accessed November 18, 2014.

(19.) Technical Manual 5-662: Swimming Pool Operation and Maintenance. Washington, DC: US Dept of the Army; 1986:4-1. Available at: http://army pubs.army.mil/eng/DR_pubs/dr_a/pdf/tm5_662. pdf. Accessed November 18, 2014.

Lisa Raysby Hardcastle, PE

MAJ Matthew Perry, MS, USA

CPT Ashley Browne, MS, USA

AUTHORS

Ms Hardcastle is a Supervisory Environmental Engineer and Deputy Chief of the Environmental Health Engineering Division, US Army Public Health Command Region-West, Joint Base Lewis-McChord, Washington.

MAJ Perry is Chief, Environmental Health Engineering Division, US Army Public Health Command Region-West, Joint Base Lewis-McChord, Washington.

CPT Browne is the Environmental Science Engineering Officer-in-Charge, Environmental Health Engineering Division, US Army Public Health Command Region-West, Joint Base Lewis-McChord, Washington.

Figure 2. Recreational water-associated outbreaks of
gastroenteritis, by type of exposure and etiology-United States,
20012010. Data from CDC

(http://www.cdc.gov/healthywater/surveillance/recreational/
figures.html).

PREVENTIVE MEDICINE OVERSIGHT OF SPLASH PADS ON MILITARY
INSTALLATIONS

Type of Exposure: (N=235)

Untreated water   26.8%

Etiology: Untreated Water (n=63)

G intestinalis        3.2%
Other *               12.7%
E coli                15.9%
Shigella spp          14.3%
Cryptosporidium spp   15.9%
Norovirus             19.0%
Unidentified          19.0%

Etiology: (N=235)

G intestinalis        3.4%
Other *               5.1%
E coli                6.0%
Shigella spp          6.8%
Norovirus             8.5%
Unidentified          10.2%
Cryptosporidium spp   60.0%

Etiology: Treated Water (n=172) ([dagger])

E coli                2.3%
Other *               2.3%
G intestinalis        3.5%
Shigella spp          4.1%
Norovirus             4.7%
Unidentified          7.0%
Cryptosporidium spp   76.2%

* Other includes outbreaks caused by Salmonella, Campylobacter,
Plesiomonas, cyanobacterial toxin(s), or multiple etiologies.

([dagger]) Sum of percentages does not total 100.0% due to
rounding.

Note: Table made from pie chart.
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Author:Hardcastle, Lisa Raysby; Perry, Matthew; Browne, Ashley
Publication:U.S. Army Medical Department Journal
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Date:Jan 1, 2015
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