Validation of Questionnaire Methods to Quantify Recreational Water Ingestion.

Swimming pool water ingestion volumes are necessary for assessing infection risk from swimming. Pool water ingestion volumes can be estimated by questionnaire or measuring a chemical tracer in swimmer urine. Questionnaires are often preferred to the chemical tracer method because surveys are less time consuming, but no research exists validating questionnaires accurately quantify pool water ingestion volumes. The objective of this study was to explore if questionnaires are a reliable tool for collecting pool water ingestion volumes. A questionnaire was issued at four pool sites in Tucson, Arizona to 46 swimmers who also submitted a urine sample for analyzing cyanuric acid, a chemical tracer. Perceived ingestion volumes reported on the questionnaire were compared with pool water ingestion volumes, quantified by analyzing cyanuric acid in swimmer urine. Swimmers were asked if they swallowed (1) no water or only a few drops, (2) one to two mouthfuls, (3) three to five mouthfuls, or (4) six to eight mouthfuls. One mouthful is the equivalent of 27 mL of water. The majority (81%) of swimmers ingested <27 mL of pool water but reported ingesting >27 mL ("one mouthful") on the questionnaire. More than half (52%) of swimmers overestimated their ingestion volume. These findings suggest swimmers are over-estimating pool water ingestion because they perceive one mouthful is <27 mL. The questionnaire did not reliably collect pool water ingestion volumes and should be improved for future exposure assessment studies. Images of the ingestion volume categories should be included on the questionnaire to help swimmers visualize the response options.

Sources of pharmaceuticals and personal care products in swimming pools.

Pharmaceuticals and personal care products (PPCPs) in swimming pool water are hypothesized to originate from fill water and anthropogenic sources like urine, sweat, swimwear and body surfaces. However, research exploring PPCP origins in pools is lacking. This research investigates PPCP sources at 31 swimming pools. Pool water was analyzed for 24 representative PPCPs using advanced liquid chromatography-mass spectrometry techniques. Fill water was analyzed as a contamination source and to determine if swimmers introduce PPCPs to pools. Results show every PPCP in fill water was present in pools except one, suggesting fill water is a PPCP source at pools. The presence of the antidepressant fluoxetine in 26% of pools and 0% of fill water indicates swimmers introduce pharmaceuticals. The flame retardant (tris(2-carboxyethyl)phosphine (TCEP)) was present 48% more frequently in pool than fill water, suggesting TCEP is introduced by body surfaces or swimwear. Enforcing showering and bathroom breaks is recommended to reduce PPCP contamination from swimmers.

Cryptosporidium risk from swimming pool exposures.

BACKGROUND: Infection risk estimates from swimming in treated recreational water venues are lacking and needed to prioritize public health interventions in swimming pools. Quantitative infection risk estimates among different age groups are needed to identify vulnerable populations. High risk populations can be targeted during public health interventions, like education campaigns and pool operation improvements. OBJECTIVES: This study estimated per-swim and annual Cryptosporidium infection risks in adults (>18) and children (≤18) using new experimental data collected in the U.S. on swimmer behavior. METHODS: Risks were estimated using oocyst concentration data from the literature, and data collected in this study on pool water ingestion, swim duration and pool use frequency. A sensitivity analysis identified the most influential model variables on infection probability. RESULTS: The average estimated risk of Cryptosporidium infection was 2.6×10-4 infections/swim event. The per-swim risk estimate in the present study differed from others because behavior data (ingestion rates, swim duration, and visit frequency) were collected in different countries and varied from U.S. estimates. We found swimmer behaviors influence infection risk. This is the first study to report annual risk of Cryptosporidium infection among swimmers by age group. Using U.S. exposure data, annual risk was estimated at 2.9×10-2 infections/year for children and 2.2×10-2 infections/year for adults. Annual risk for all swimmers was estimated at 2.5×10-2 infections/year from swimming in treated recreational water venues. Due to increased ingestion and swim duration, child swimmers had the highest annual risk estimate. Cryptosporidium concentration is the most influential variable on infection probability. CONCLUSIONS: Results suggest the need for standardized pool water quality monitoring for Cryptosporidium, education, development of interventions to reduce ingestion, consideration of behaviors unique to swimming populations in future risk assessments and improvement of oocyst removal from pool water. Child swimmers were the most vulnerable sub-population, and should be targeted in healthy swimming education campaigns.

Assessment of swimmer behaviors on pool water ingestion.

Enteric pathogens in pool water can be unintentionally ingested during swimming, increasing the likelihood of acute gastrointestinal illness (AGI). AGI cases in outbreaks are more likely to submerge heads than non-cases, but an association is unknown since outbreak data are self-reported and prone to bias. In the present study, head submersion frequency and duration were observed and analyzed for associations with pool water ingestion measured using ultra high pressure liquid chromatography - tandem mass spectrometry. Frequency of splashes to the face was also quantified. Reliable tools that assess activities associated with pool water ingestion are needed to identify ingestion risk factors and at-risk populations. Objectives were to determine if the observed activities were associated with ingestion, and to test environmental sensor and videography assessment tools. Greater frequency and duration of head submersion were not associated with ingestion, but frequency of splashes to the face, leisurely swimming, and being ≤18 were. Videography was validated for assessing swimmer head submersion frequency. Results demonstrate ingestion risk factors can be identified using videography and urine analysis techniques. Expanding surveys to include questions on leisure swimming participation and frequency of splashes to the face is recommended to improve exposure assessment during outbreak investigations.