Talk to Patients About Recreational Water Health Risks

Michele C. Hlavsa, RN, MPH


July 18, 2011

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Hi. I'm Michele Hlavsa, Chief of CDC's Healthy Swimming Program. Thanks for choosing to watch this CDC Expert Video Commentary on Medscape. I would like to talk to you today about a common problem -- recreational water illnesses (RWIs). RWIs are caused by pathogens transmitted by ingesting, inhaling aerosols from, or having contact with contaminated water in swimming pools and other recreational water venues.

The number of RWI outbreaks reported annually has increased dramatically in recent years. In 2007, 2.4 million US healthcare visits resulted in a diagnosis of acute otitis externa, commonly referred to as swimmer's ear.[1] Annually, ambulatory-care clinicians spend nearly 600,000 hours treating acute otitis externa. In other words, acute otitis externa and other RWIs are common and take up a substantial amount of clinicians' time, but RWIs can be easily prevented.

Studies show that the swimming public believes that chlorine instantly kills all pathogens. These data also show that swimmers don't think about swimming as a shared water experience. Unfortunately, these misconceptions lead to risky behaviors, such as swimming during diarrheal illness and swallowing recreational water, which lead to transmission of pathogens that cause RWIs. As clinicians, it's up to us to educate our patients and dispel misconceptions that lead to illness.

Here are 5 simple prevention messages you can share with your patients to help them proactively protect their health every time they swim.

  1. Don't swim while ill with diarrhea. A person with diarrhea can easily contaminate the water with fecal matter and introduce enteric pathogens into the water. RWI outbreaks caused by enteric pathogens have increased more than 100%, from 37 in 1999-2000 to 81 in 2007-2008.[2,3] Because of its tough outer shell, the coccidian Cryptosporidium can survive in a well-maintained pool or other chlorinated recreational venue for more than 10 days. Outbreaks of cryptosporidiosis are driving the increase in the number of RWI outbreaks reported annually and can spread into community-wide, and even statewide, outbreaks.

  2. For patients with cryptosporidiosis, don't swim for an additional 2 weeks after diarrhea has resolved. CDC and the American Academy of Pediatrics[4] recommend this step because of the prolonged excretion of Cryptosporidium after cessation of diarrhea, the potential for intermittent diarrhea that might cause infected people to think symptoms have resolved, and the increased transmission potential in chlorinated recreational water venues because of the parasite's high chlorine tolerance.

  3. Don't swallow the water. Pathogens that cause diarrheal illness can be transmitted when swimmers swallow contaminated water. We don't drink the water in our bath tubs; why would we drink the water we swim in?

  4. Keep ears as dry as possible and dry ears thoroughly after swimming. CDC, the American Academy of Otolaryngology, and the American Academy of Pediatrics have recently released updated recommendations to prevent acute otitis externa. Using a bathing cap, ear plugs, or custom-fitted swim molds when swimming can help keep water out of the ears. Pulling the earlobe in different directions while the ear is faced down can help drain water out. If your patient has frequent episodes of acute otitis externa, consider prescribing prophylactic alcohol-based ear drops or a 1:1 mixture of rubbing alcohol and white vinegar. Drops should not be used by persons with tympanostomy tubes or ear tubes, damaged ear drums, outer ear infection, or ear drainage.

  5. Don't swim when you have open wounds. Open wounds can be sites of entry for pathogens, so people with open wounds should refrain from swimming until the wound is healed. Another option is to wear a waterproof occlusive bandage to cover the wound while swimming. Although swimming with open wounds represents a risk for the person with the wound or sore, CDC is not aware of data indicating that this practice puts the health of other swimmers at risk.

We realize that there is little time for patient education in a busy practice. To increase awareness and expedite communication, CDC has created a number of public-targeted prevention materials. To access these materials and more information on healthy swimming, visit our Website. Thanks for tuning in.

Web Resources

CDC Education and Information for Health Professionals on Healthy Swimming and Recreational Water

CDC Healthy Swimming/Recreational Water: Recreational Water Illness

CDC Healthy Swimming/Recreational Water: How Can We Prevent Recreational Water Illnesses?

CDC Healthy Swimming/Recreational Water: Swimmer's Ear-Otitis Externa

CDC Healthy Swimming/Recreational Water: Swimmer's Ear Prevention

CDC Healthy Swimming/Recreational Water: Resources and Publications

CDC Healthy Swimming/Recreational Water: Frequently Asked Questions

CDC Healthy Swimming/Recreational Water: Triple A's of Healthy Swimming

AAP News: Don't Let Swimmer's Ear Keep You Out of the Water

Recreational Water Illness: What Every Clinician Needs to Know

Michele C. Hlavsa is an epidemiologist with the Healthy Swimming Program in the Waterborne Disease Prevention Branch at the Centers for Disease Control and Prevention in Atlanta, Georgia. She has a master's degree in public health in epidemiology from Emory University and is a graduate of the Epidemic Intelligence Service, CDC's disease detective group. She has worked on a number of outbreak investigations of waterborne and foodborne diseases in her 8 years at CDC.

Michele collaborates with state and local health authorities and the private sector to decrease the risk for recreational water illness and promote healthy swimming. Her particular focus is studying the transmission of pathogens, such as Cryptosporidium, that cause recreational water illness and developing appropriate prevention and control measures.


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