A Perfect Storm

Are Water and Air Quality on Your Radar Screen Yet?

By Joseph Ryan

It's in the water: Thousands of swimmers in western states came down with severe nausea and diarrhea last summer in headline-grabbing crypto outbreaks that forced one state to ban all toddlers from pools for a month.

It's in the air: Nearly 200 swimmers at a large aquatic theme park in Ohio complained to health officials last year of flu-like symptoms, coughing and wheezing, prompting federal and local authorities to swoop in with a battery of air tests.

And now it's on your customers' minds:

"This is all going to lead to more attention on these issues in the public and end up costing pools that aren't up to standards," said Tom Lachocki, CEO of the National Swimming Pool Foundation (NSPF).

Industry experts largely agree that pool operators and managers across the nation should be bracing for a rapid increase in scrutiny on air and water quality issues in the coming years. To stay ahead of the curve, experts say now may prove to be the right time to start reviewing your filtration methods, disinfection policies, staff training and customer education methods.

A perfect storm of increased maladies, mounting research and growing attention appears to be brewing around the aquatic recreation industry.

For one, officials at the U.S. Centers for Disease Control & Prevention (CDC) are looking at two years of dramatic increases in recreational water illness (RWI) outbreaks. More, and potentially larger, spikes are expected to follow.

On another front, federal and state attention on air quality issues at indoor aquatic facilities is growing. Plus, several new standards are set to come out for aquatic facility managers and operators to adhere to no matter the added cost.

All of this promises to bring attention to the issue from the press, as well as the public.

"To keep membership and to keep people coming back to their pools, (operators and managers) are going to have to address these issues. There is going to be a new public sensitivity to it," said Keith Coursin, president of a Milwaukee-based dehumidifier company and chair of a research panel analyzing pool ventilation standards for the American Society of Heating, Refrigerating, and Air-Conditioning Engineers.

"It is no longer going to be that you know you have a problem and can just keep quiet and think no one else is going to know," Coursin said.

WATER WORRIES

The largest problem facing aquatic facilities—as far as the public trust goes—has been the steadily increasing number of RWI outbreaks. These include a wide range of parasites, viruses and bacteria at treated facilities, including E. coli, but the most widespread of these has been Cryptosporidium, most commonly called "crypto."

The word crypto should send chills down the spine of any aquatic facility operator. It is a tough, tiny parasite that can't easily be killed by normal chlorine levels or sand filtering.

"This is the one that we really need to be concerned about," said Dr. Fontaine C. Piper, former director of heath and exercise sciences at Truman State University.

Crypto—most often leaked into pools from an infected host's diarrhea or stool—inflicts nausea, vomiting, fever, stomach cramps, dehydration and diarrhea. More serious symptoms can develop in young children, pregnant women, the elderly and those with HIV/AIDS, cancer or recent organ transplants.

Crypto is particularly ruthless because those who spread it may not even know they are infected. The parasite can continue to spread from a host up to two weeks after symptoms go away, and it can live outside of a host for an extended period of time.


Once an outbreak is detected—often days after infection, because symptoms don't appear for up to a week—federal and local health officials have been known to shut down aquatic facilities and alert the media.

In the past few years, however, crypto was apparently only starting its attack on the aquatic industry. From 2003 to 2005, the number of reported cases of crypto rose from 3,505 in the nation to 8,269. The official number of crypto cases for 2006 is expected to spike dramatically when the tally comes out this year.

Consider this: The CDC put out a special report in the middle of last summer to report that 18 total outbreaks had already been recorded for 2006, six more than had been documented in 2003 and 2004 combined. Moreover, outbreak-related cases of crypto only account for about 40 to 50 percent of all reported cases.

If early reports of 2007 outbreaks are any indication, the crypto increase will continue to skyrocket when that report comes out next year.

Crypto made headlines across the western states last summer when a series of outbreaks racked up 2,357 reports of illness from swimmers at public pools. Most of the reports came from Utah, where 1,900 cases were recorded within the last two months of the summer swimming season. More than 60 of those stricken had to be hospitalized.

The sharp rise prompted local health officials to ban all children under the age of 5 from swimming pools for all of August. Regional bans on diaper-wearing children and adults continued into the fall season.

Utah, though, was not alone. Increases were reported in Idaho (230 cases over 23 the previous year), South Dakota (108 cases over 31 the previous year) and Colorado (50 cases in August over an annual average about 12).

Crypto outbreaks in Kansas City forced officials there to shut down several public pools on the eve of Labor Day weekend, a pool operator's worst nightmare, according to media reports.

"These are things no recreation department ever wants to be involved with," Lachocki said, noting the damage to business and public perception such high-profile cases cause the industry.


CDC officials are attributing the increase in crypto outbreaks to better reporting practices as well as more people using aquatic facilities.

It remains unclear if there is an actual increase in infected pools across the nation. But that won't matter to the swimming public, especially when the CDC institutes a new electronic outbreak reporting program next year that is expected to lead to even more dramatic leaps in official infection tallies.

The increase in illness outbreaks is not coming without notable action from the CDC.

Last May, CDC officials set up a steering committee of industry professionals to develop a national model for aquatic facility regulation. The model is expected to outline what types of filtration and disinfection techniques should be employed at aquatic facilities, along with a possible standard for pool operator training.

Once released, potentially next year or earlier, the model regulations will be a guideline for other states and municipalities. As crypto cases continue to make headlines, it is relatively certain that public pressure will increase for local health officials to adopt the new, likely stricter rules.

Essentially, this chain of events means higher standards for aquatic facility operators that will likely include the implementation of more costly disinfection processes than the typical chlorine-and-sand-filter combination. CDC officials alluded to such in their recent special report detailing the sweeping crypto outbreaks in the summer of 2007.

"Reducing the risk for future outbreaks will require changes in pool water disinfection practices," the report reads. "A multifaceted approach for prevention of (crypto) in treated water venues must address operational, technological, and behavioral factors related to recreational water use."

WHAT'S THAT SMELL?

While crypto has been a known threat for years, air quality at indoor pools is a relative newcomer to the list of concerns for recreational swimmers. The public worry on this issue shows no sign of dissipating as reports of air quality problems at pools across the country continue to crop up in the media.

"Indoor air quality has always been a concern within the industry, but there has been more attention brought to it in the public lately," Piper said.

Most notably, nearly 200 complaints of respiratory problems and rashes were reported by more than 600 adults and children who attended a large water theme park in Mason, Ohio, during the first three months of 2007.

The reports likely scared off some customers and brought in both federal and local heath officials, who repeatedly tested the air and water. The problems were believed to be caused by chloramines—a natural byproduct from chlorine interacting with organic compounds like human sweat, urine and skin.

When inhaled at high levels, chloramines—which include various known carcinogens—are known to induce asthma attacks in asthma sufferers, cause breathing problems for those without asthma and cause red, itchy eyes.

Chloramines in the air give off that acidic, sweet smell that swimming pool patrons may come to associate with chlorine. But that smell actually means there is not enough chlorine in the pool because chloramines are given off into the air when chlorine can't handle the amount of organic material in the water.

Whether air quality is a widespread issue or not remains unclear. Proper and efficient reporting standards of such outbreaks have not been streamlined like with crypto. At the same time, reports of air quality complaints are easy to come by. The CDC put out a special report on two, unrelated 2004 outbreaks in rural Illinois that affected several dozen people. In Nebraska on Christmas Day in 2006, one 6-year-old child had to be hospitalized overnight with a swollen throat and about two dozen others experienced breathing problems from an indoor hotel pool. Several of those complaining of issues had not even set foot in the water.

"The measurements in the pool were way out of whack," said Bryan Buss, a lieutenant commander of the U.S. Public Health Service who studied the outbreak. "That really spurred our interest."

While minor initial contact irritations with airborne chloramines are relatively common—and often easily treated once removed from the environment—there is conflicting data on whether or not there can be more lasting problems. Some studies have suggested a link between airborne chloramines and other chlorination byproducts and bladder or intestinal cancer. A groundbreaking study released in Europe suggested there was a direct link to childhood asthma.

However, some experts strongly disagree that any long-term negative impacts have been proven.

"Some studies have raised suspicions, but generally when people have looked further they have found there is no real reason for health concerns in the United States," said Robert G. Tardiff, CEO of The Sapphire Group, a global health science risk management consultant group based in Maryland.

For now there are no pool-specific standards for air quality across the nation. Aside from traditional air quality building code standards, scientists are still working to find out what levels of specific chemicals make air dangerous for people and what levels are nothing to worry about. Experts, though, also believe that there will come a time, perhaps just five or 10 years down the road, when those standards will exist.

"It is not something that is going to happen tomorrow," Piper said. "But it is on the radar."

Meanwhile, an expert panel is set to release early this year the results of an industry-funded study on how much ventilation is necessary to keep an indoor pool facility safe for the swimming public. The project, now 18 months in the making, required the building of a model-size indoor pool for lab tests, and it is already gaining much attention across the industry.

"Everyone wants this information," said Coursin, who is heading the ASHRAE committee overseeing the project. "This research is garnering a lot of interest."

The study is expected to determine the amount of byproducts different pools spew into the air and the required ventilation frequency to remove them. The study material will be followed up with further research by other industry groups.

"This is an item that many segments of the industry should be concerned about," Coursin said.


An Ounce of Prevention=A Dose of Education

One of the simplest actions aquatic facility mangers can take to ensure patron safety is to make sure the staff knows what they are doing when handling dangerous pool chemicals.

Currently 30 states do not require certification of pool operators, leaving a wide swath of aquatic facilities across the nation that could legally allow uneducated employees to roll the dice with patron safety. But it is entirely possible that the U.S. Centers for Disease Control & Prevention (CDC) may soon come out with model regulations for states that include mandatory training for pool operators. Growing public outrage over crypto outbreaks and poor air quality are expected to spur lawmakers to adopt such strict regulations at an increasing rate.

Responsible pool managers, experts say, should consider hiring trained staff regardless of the current laws, because in the end it may cost them customers. It is also simply the right thing to do.

"(Education) is really going to affect their ability to manage the pool properly," said Bryan Buss, a lieutenant commander for the U.S. Public Health Service based in Nebraska.

Following an outbreak last year of respiratory ailments with guests at an indoor hotel pool—which actually sent a 6-year-old child to the hospital with a swollen throat—Buss conducted a statewide study of pool operators and training. He had found that hotel staff in the incident were not properly trained to operate the pool and therefore closed off ventilation while allowing inadequate chlorine levels.

In his study of pool inspection violation records across the state, Buss found that aquatic facilities without trained staff had about twice as many pH and chlorine-level violations as those facilities with trained staff.

Buss' research is being touted in several states as a reason to require broad training standards for pool operators, especially at hotels and other low-key aquatic facilities that might not want to spend the extra money.

"If (pool owners) aren't required to do it, I don't think they are compelled to do it, because unless a patron complains, they can stay off the radar screen," Buss said.

While course requirements vary across the 20 states that do require pool operator certification, there are standard national courses offered by such organizations as the National Swimming Pool Foundation and the National Recreation and Park Association. Several national training courses are listed at www.cdc.gov/healthyswimming/courses.htm.


STAYING AHEAD OF THE CURVE

Thankfully, pool operators and mangers do have options to combat the growing danger of RWIs and air pollution as well as the growing public perception that aquatic facilities simply aren't safe options for recreation.

"The reason this is an issue is not because there are not tools to use in the war," Lachocki said. "But it is because people just aren't using the tools."

Water quality and air quality at indoor pools are often directly related. A dirty pool, or a pool with unacceptable pH and chlorine levels, will send chloramines and other pollutants into the air that can impact your customer's health and your reputation.

Experts agree that the first and foremost thing pool operators can do is ensure their water chemistry is in balance at all times. A properly disinfected pool can combat most germs and reduce the chances of air pollution. Yet, even well-managed pools can be prone to such problems, experts say. That is because of the various factors that can play a role in the pool's chemistry. For one, sudden increases in the number of swimmers can overburden chlorine and pH levels.

"Even if you have a four- or five-hour water turnover, it still may not be enough if you have an ultra-high swimmer load," Piper said.

Piper recommends that pool operators consider instituting and strictly enforcing swimmer load guidelines. In general, most pools should have a limit that equates to about one swimmer to every 20 to 25 square feet, Piper said. If chlorination and disinfection are a particular issue, he said, perhaps change that regulation to one swimmer for every 30 square feet.

"In some cases that is the only way to resolve some of these air and water quality issues," he said.

Outside the pool, options for better disinfection and filtering continue to multiply for aquatic facility managers. Cost, of course, is always an issue, but UV filters and ozone technology are growing in popularity and availability, experts note. UV and ozone have the added benefit of limiting the amount of chlorine that is needed, thus reducing the chances of air pollution and related illnesses, said Gary Toner, president of Cincinnati Pool Management.

For many pool operators, though, Toner agrees that such items may still be cost-prohibitive. In that case, consider trying filtration options other than the standard sand, such as diatomaceous earth, if possible. Products like Zeobrite, which is reportedly courser than sand, claim to have a better effective rate against crypto than regular sand. New items are coming on the market every day, too, including one that uses finely crushed glass particles. If upgrading your filter media is not an option, there are coagulates on the market that when added to the water act to bind bacteria, viruses and parasites together so they can more easily be trapped by regular filters.

All aquatic facilities will have different issues to consider when weighing these options, including budget, pool size, space and clientele. However, experts say it is critical that considerable weight is given to customer health in the equation.


When Accidents Happen

No matter how well managed an aquatic facility may be, nothing can prevent body fluid accidents in or near the water. Such accidents can endanger the health of swimmers if not handled properly.

The first step to managing any accident effectively is to quickly and accurately spot and identify the issue. Diarrhea and formed-stool accidents at pools, while unpleasant, are not all that uncommon, and each requires different approaches for proper cleaning.

Centers for Disease Control & Prevention (CDC) officials note that diarrhea accidents should be treated with the greatest care because they are more likely to spread dangerous bacteria, viruses and parasites, like cryptosporidium.

In both cases, however, all patrons must be directed to leave the pool and staff should remove as much material as possible with skimmers, nets and scoops. Vacuuming the material is not recommended and all used items should be disinfected after use.

Shut down all aquatic facilities that are connected to the infected pool via filters.

With a diarrhea accident, the pool's chlorine level needs to be raised to 20 parts per million for at least eight hours to ensure all potential crypto and bacteria is killed.

With a formed stool accident, staff can raise the chlorine level to 2 ppm for about 30 minutes before letting patrons back in the pool.

In each case be sure the pH level is maintained between 7.2 and 7.5 throughout the process.

Experts recommend that aquatic facility managers ensure their staff knows how to handle each outbreak.

"You have to educate," said Tom Lachocki, CEO of the National Swimming Pool Foundation.


EDUCATE YOUR SWIMMERS

Aside from large changes in pool equipment, aquatic facility managers can also take other avenues to protect against water and air quality issues. Education and pool policies seem to top the list for most experts.

Customers should be advised, mostly through postings, not to swim for at least two weeks after having had diarrhea. For children's pools, experts recommend instituting a break every 30 minutes to encourage the tots to use the bathroom.

Shower-before-you-swim regulations must be strictly enforced and displayed. After all, the less sweat and skin that get in the pool, the more likely pool chemistry will stay in balance. Toner recommends installing a shower near the pool in plain view to further encourage and regulate the policy.

As for air quality, make sure the facility has adequate ventilation and keep it running, even in winter.

"We are always surprised that we find people who shut those outside dampers to save the energy. It happens all the time," Coursin said.

But soon, experts seem to agree, simply making modest moves toward a cleaner and healthier aquatic facility will no longer be enough.

Bottom line: At some point—and it may be sooner rather than later—pool operators may not have a choice when it comes to protecting against air and water quality problems.

"Five years ago I think people could claim ignorance," Lachocki said. "We can't put our head in the sand with all the information we have today. Irresponsibleness never attracts more customers."



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