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.

Swimming Pool safety and prevention at the time of Covid-19: a consensus document from GSMS-SItI.

Public health measures to cope with the Covid-19 pandemic, imposed also a shutdown of sports facilities and swimming pools. Safety issues related to recreational waters were emerging during the lockdown, rising concerns on how and when reopening pools and on how improve their management while SARS-CoV-2 is circulating in the population. The GSMS-SItI, Working Group on Movement Sciences for Health of the Italian Society of Hygiene Preventive Medicine and Public Health, discussed and summarized some indications for a suitable preventive approach. Several measures are highlighted, including social distancing, optimized water management, airflow and microclimatic parameters in the pool as well in the annexed rooms, verification of sanitation procedures. The GSMS-SItI underlines that prevention should be based on monitoring of the local epidemiological situation and on the constant collaboration with the local health authority and the national health service.

An innovative swimming pool water quality index (SPWQI) to monitor and evaluate the pools: design and compilation of computational model.

This research aimed to develop an index known as swimming pool water quality index (SPWQI) for quantifying the water pollution potential. The index is a quantitative tool to show the data on the water quality of swimming pools consistently. It makes summarizing the complex data on water quality possible and paves the way for its communication to the general public and decision makers. In this study, the SPWQI has been formulated according to the literature review and Delphi method. According to literature review and the total judgment of the panelist (23 experts specialized in environmental health engineering), 13 physicochemical and biological parameters along with their weights were selected for inclusion in the SPWQI. The results indicated the possibility of calculating a single numerical value (i.e., SPWQI), which indicates the combined effect of significant selected parameters on water quality. In addition, biological composition (47%) had a strong preference weighting than physical and chemical parameters in evaluating the index. Next, it was attempted to implement a novel and user-friendly mathematical model for evaluating the SPWQI. Then, the model accuracy and performance was confirmed by a case study. Overall, it could be said that the assessment of SPWQI sheds light on the concurrent power of several pollutants and can help the authorities to decide upon water quality management and treatment approaches.

[Legal and management issues of public health requirements for swimming pools in Regione Toscana]. / Inquadramento giuridico e gestione delle attività svolte al fine del mantenimento dei requisiti igienico-sanitari negli impianti natatori nella 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.

Molecular identification of waterborne free living amoebae (Acanthamoeba, Naegleria and Vermamoeba) isolated from municipal drinking water and environmental sources, Semnan province, north half of Iran.

The present study tested 80 samples of municipal, geothermal and recreational water samples for the occurrence of waterborne free living amoebae (FLA) including Acanthamoeba, Balamuthia mandrillaris, Vahlkampfiids and Vermamoeba in Semnan province, North half of Iran. Four sets of primers including JDP1,2 primers, ITS1,2 primers (Vahlkampfiids), 16S rRNABal primers (Balamuthia mandrillaris) and NA1,2 primers (Vermamoeba) were used to confirm the morphological identification. From the 80 water samples tested in the present study, 16 (20%) were positive for the outgrowth of free living amoebae based on the morphological page key. Out of the 34 municipal water samples, 7 (20.6%) were positive for outgrowth of Free living amoeba, belonging to Vermamoeba, Naegleria and Acanthamoeba using molecular tools. Three out of the six investigated hot springs were also contaminated with Naegleria spp. Sequencing of the ITS1,2 region of the Vahlkampfiid isolates revealed the highest homology with N. gruberi (2 isolates), N. australiensis (1 isolate) and N. pagei (3 isolates). This is the first report of N. gruberi in the country. Using morphological and molecular analysis, Balamuthia mandrillaris was undetected in all the water samples. The present study further confirmed the occurrence of potentially pathogenic waterborne free living amoebae in habitats with high human activity. It is of utmost importance that more studies are conducted to evaluate the niches of B. mandrillaris and N. fowleri in Iran and worldwide. Such investigations regarding the relevance of FLA as a hazard to humans, should be brought to the notice of the health authorities.

Indoor swimming pool environments and self-reported irritative and respiratory symptoms among lifeguards.

A web survey was conducted among 870 lifeguards (current and former) to assess the relationship between exposure to indoor swimming pool environments and respiratory health. Associations between respiratory symptoms and asthma with varying lengths of occupational exposure were assessed by multiple logistic regression. Lifeguards exposed more than 500 hours in the previous 12 months experienced more cough (adjustedOR = 2.54, IC95 % = 1.51-4.25), throat (aOR = 2.47, IC95 % = 1.44-4.24) and eye irritation (aOR = 4.34, IC95 % = 2.52-7.50) during this period than non-exposed lifeguards. Upper and lower respiratory symptoms while on duty were related to duration of lifetime exposure (> 500 days vs. ≤ 50 days: Upper aOR = 5.84, IC95 % = 3.60-9.50; Lower aOR = 2.53, IC95 % = 1.58-4.06). Physician-diagnosed asthma was high among lifeguards (23 %). Highly exposed asthmatic lifeguards (> 500 hours) over the previous 12 months had a significantly higher risk (aOR = 3.74, IC95 % = 1.39-10.02) of suffering from asthma attack(s) than non-exposed asthmatic subjects. Exposure to indoor swimming pool environments is related to respiratory symptoms among lifeguards.

Development of the laboratory prototype "CavyPool" for assessing treatments and materials for swimming pools.

BACKGROUND: Hygiene and surveillance in swimming pools are established by WHO Guidelines and national laws. Progress in water management and pool construction is revolutionizing the field, introducing new materials, systems, disinfection procedures or monitoring markers. Innovation advances challenge the upgrading of safety and quality in pools and the appropriate implementation of guidelines. STUDY DESIGN: In order to provide a device for laboratory test, a prototype was realized and applied to study and compare swimming pool materials and treatments. METHODS: A pool scale-model was engineered and evaluated by computational fluid dynamics algorithms. An automated real time monitoring assured steady state. Critical control points along the water circuit were made accessible to allow the placing of different biocides or water sampling. Simulations were safely performed in a standard hood. Materials for pool surfaces and pipelines were evaluated for biofilm formation under different disinfection conditions. Adherent microorganisms were assayed by mfDNA analysis using real time PCR. RESULTS: The prototype reached the steady state within 5-25 hours under different conditions, showing chemical, physical and fluid-dynamic stability. A method was optimized for testing materials showing their different response to biofilm induction. Several innovative PVC samples displayed highest resistance to bacterial adhesion. CONCLUSIONS: A device and method was developed for testing swimming pool hygienic parameters in laboratory. It allowed to test materials for pools hygiene and maintenance, including biofilm formation. It can be applied to simulate contaminations under different water treatments or disinfection strategies. It may support technical decisions and help policymakers in acquiring evidences for comparing or validating innovative solutions.

[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]. / Alcune considerazioni sulla revisione della normativa igienico-sanitaria per la gestione di piscine ad uso natatorio e la Consultazione Nazionale del Ministero della Salute.

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.

A statewide outbreak of Cryptosporidium and its association with the distribution of public swimming pools.

In order to characterize the association between county-level risk factors and the incidence of Cryptosporidium in the 2007 Iowa outbreak, we used generalized linear mixed models with the number of Cryptosporidium cases per county as the dependent variable. We employed a spatial power covariance structure, which assumed that the correlation between the numbers of cases in any two counties decreases as the distance between them increases. County population size was included in the model to adjust for population differences. Independent variables included the number of pools in specific pool categories (large, small, spa, wading, waterslide) and pool-owner classes (apartment, camp, country club or health club, hotel, municipal, school, other) as well as the proportion of residents aged <5 years. We found that increases in the number of bigger pools, pools with more heterogeneous mixing (municipal pools vs. country club or apartment pools), and pools catering to young children (wading pools) are associated with more cases at the county level.

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.

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.

[New rules of the bathing water quality management]. / Nowe zasady zarzadzania jakoscia wody w kapieliskach.

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.

[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.

Disease outbreaks associated with untreated recreational water use.

Annual overviews of waterborne disease outbreaks associated with untreated recreational water use provided by authorities responsible for bathing-water quality and public health in The Netherlands revealed 742 outbreaks during 1991-2007 mainly comprising of skin conditions (48%) and gastroenteritis (31%) and involving at least 5623 patients. The number of outbreaks per bathing season correlated with the number of days with temperatures over 25°C (r=0.8-0.9), but was not reduced through compliance with European bathing-water legislation (r=0.1), suggesting that monitoring of faecal indicator parameters and striving for compliance with water-quality standards may not sufficiently protect bathers. Bathing sites were prone to incidental faecal contamination events or environmental conditions that favoured the growth of naturally occurring pathogens. Identification of all possible contamination sources, awareness of changes that might negatively affect water quality, and provision of adequate information to the public are important preventive measures to protect public health.

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.

Modifying the food supply at a community swimming pool: a case study.

ISSUE ADDRESSED: We report on a process evaluation of a project that aimed to replace energy-dense, nutrient-poor (EDNP) items at a community swimming pool kiosk. The analytic framework was the Analysis Grid for Environments Linked to Obesity (ANGELO). To contribute to health promotion practice in recreational settings, the process evaluation sought to determine the extent to which project'controversies' modified project objectives and strategies. METHODS: The case study method captured the project narrative. The primary data were interviews with key project participants, supplemented with project records and media articles.These were analysed thematically. RESULTS: The socio-cultural and political environments, particularly the capacity to exercise choice in relation to ENDP products, had considerable influence on the project. In the face of two controversies -"I thought everyone was signed up to it"and "We can't deny the kiddies their ice-cream" it was necessary for the project partners to modify the objectives and strategies and substantially change the target. CONCLUSIONS: The setting is highly responsive to both the micro and macro socio-cultural and political aspects of the environment.