What’s In Your Water?Avoiding Water Quality Incidents

November 15, 2018

Ellen Meyer, Lonza

What’s In Your Water?Managing Risk

Chemical incidents

• How to avoid chemical incidents

Pathogen incidents

• How to avoid pathogen incidents

Swimmers

Chemicals

Pathogens

• The Centers for Disease Control and Prevention (CDC)

– Non-regulatory federal agency

– Model Aquatic Health Code

• https://www.cdc.gov/mahc/index.html

– Healthy Swimming useful information

• https://www.cdc.gov/healthywater/swimming/index.html

– National Institute for Occupational Safety and Health (NIOSH)

• https://www.cdc.gov/niosh/

• Chemical safety information

Guidelines and Information

• Local State/County/City Codes

– Health Codes- construction and operation of aquatic facilities

– Fire Codes

– Building Codes (plumbing, electrical, etc.)

• Federal

– Environmental Protection Agency (EPA)- regulation of pesticides (sanitizers,

algaecides)

– Occupational Safety and Health (OSHA)- workplace safety

– Department of Homeland Security (DHS)

Regulations

• Indoor Water Park- Ohio (CDC 2009, Chen 2008)

– 665 reports of respiratory and eye irritation from patrons and lifeguards

– Local media, Health Department and CDC involved

– Substantial ventilation system modifications were made

• Indoor motel swimming pool, Nebraska 2006 (CDC 2007)

– 24 ill

– 6 year old boy hospitalized in intensive care

– Logs showed inadequate water chemistry for 26 consecutive days

Chemical Incident Case Studies

Chloramines

• California 2008-2015 (Wilken 2017)

– 9 incidents

– 9/9 Chemical feed continued without main recirculation flow

– 7/9 Main flow resumed while bathers were present

– 155 Symptomatic, 121 medical attention, 5+ hospitalized

• Outdoor municipal water park, CA (Wilken 2017)

– Chemical controller interlock failure

– Bleach (NaOCl) + muriatic acid (HCl) → chlorine gas (Cl2)

– Staff turned off chemical overfeed alarm

– 34 experienced vomiting, coughing or eye irritation

– 17 transported to hospital, one remained overnight

Chemical Incident Case Studies

Chlorine Gas

• 4,247 injuries/year median estimated Emergency Department visits due to

pool chemical-associated injuries during 2003-2012

Chemical Incident StatisticsHlavsa 2014

2012 Breakdown Actual Count Weighted estimate %

Residence 40 1,759 36%

Place of recreation or sports 10 408 8%

School 1 70 1%

Other public property 13 641 13%

Unknown 45 1,998 41%

0-17 years old 53 2,289 47%

18-45 23 850 17%

46-64 28 1,518 31%

≥ 65 5 218 4%

Chemical Incident Statistics2002-2008 for CA IA LA MI NC TX (CDC 2011)

Contributing Factor Workers %

Spill or splash of liquid or dust 61 33

Required PPE not worn/PPE inadequate 44 24

Application equipment failure 35 19

Mixing incompatible products 21 11

Not properly trained or supervised 19 10

Dust cloud or fumes generated upon opening container 13 7

Other improper storage 13 7

Chemical Incidents- Lessons LearnedHow issues are addressed in the MAHC

• Chloramines– Ventilation (MAHC 4.6.2 and 5.6.2)

– Water chemistry

– Training

• Chlorine gas– Chemical feed interlocks

– Evacuation procedures

– Training

• Chemical handling• Label directions• Safety Data Sheets (SDS)• Chemical storage and handling• Training

• ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers)

– ANSI/ASHRAE Standard 62.1 2016, Ventilation for Acceptable Indoor Air Quality

– Handbook- HVAC Applications 2015, Natatoriums

• Plus

– Alarm if <0.48 cfm/ft2

– Sufficient return air intakes shall be placed near aquatic venue surfaces such that they remove the highest concentration of airborne DBP contaminated air.

– Manual purge ≥ 2 x ASHRAE 62.1 requirement

– Qualified licensed professional commissioning, including a written statement that the amount of outdoor air meets the performance requirements

VentilationMAHC 4.6.2 and 5.6.2

Water ChemistryParameter MAHC section Minimum Maximum

Free chlorine 5.7.3.1.1 1 ppm no CYA2 ppm with CYA

10 ppm or product labelEPA maximum is 4 ppm

Cyanuric acid (CYA) 5.7.3.1.3 -- 0 ppm spas, therapy pools90 ppm all others

Combined chlorine 5.7.4.4 0.4 ppm requires action (superchlorination, water exchange, bather hygiene)

pH 5.7.3.4 7.2 7.8

Total Alkalinity, ppm 5.7.4.4 60 180

Calcium hardness, ppm 5.7.4.4 -- 2500*

Temperature, °F 5.7.4.7 -- 104

*New in 2018 MAHC

• Equipment (4.7.3)

– Feeders and controllers for disinfection and pH chemicals (4.7.3)

– NSF/ANSI-50

– At least two interlocks• Recirculation pump power monitor

• Flow meter/flow switch in return line

• Flow meter/flow switch at chemical controller

– Visual alarm if interlock activated*

• Policies (5.7.3.5)

– Bathers evacuated if interlock activated or recirculation pump is off*

– No start-up until manual evaluation by responsible supervisor or qualified operator*

– Bather re-entry ≥ 5 minutes after system start-up*

* New in 2018 MAHC

Chemical Feed Interlocks and ActionsMAHC 4.6.2 and 5.6.2

• Qualified operator training essential topics (6.1.2.1)

– Water disinfection

– Water chemistry

– Mechanical systems

– Health and safety operations

TrainingMAHC 6.1

• MAHC 4.9.2 Chemical storage spaces

• MAHC 5.9 Chemical storage and handling

• Chemical storage, handling and use in compliance with

– Local codes (fire codes, building codes)

– Occupational Safety and Health Administration (OSHA) and Environmental Protection Agency (EPA) regulations

– Manufacturer Safety Data Sheets (SDS) and labels

Chemical Handling

Pathogen Incidents

• Water Park CA, August – September 2004 (Wheeler 2007)– 244 patron illnesses, 83 consulted health care provider, 3 hospitalized

– Patrons and employees admitted swimming while ill

– Sporadic and inconsistent water chemistry records

– 30% of wading pool flow diverted away from filter and to heater

• State Park Interactive Fountain, NY, June - August 2005 (CDC 2008)– 2,307 ill

– Results from outbreak

• $5 million class action law suit

• NY state requirement for secondary treatment of spray pads

Cryptosporidium

E. Coli O157:H7

• Water Park, GA 1998 (Barwick 2000)– 26 people ill, 7 developed hemolytic uremic syndrome, 1 death

– Fecal accident in children’s pool

– Low chlorine levels documented

Legionella

• Hotel decorative fountain, IL, August 2012 (Smith 2015, Smith 2012)– 114 cases, 15 hospitalizations, 3 deaths

– No record of regular cleaning and disinfection of the fountain

• Theme Park, CA, 2017 (Orange County Health Department 2018)– 22 Cases, 18 people hospitalized, 1 Death

– Legionella found in two cooling towers

Bacteria

• 71 Outbreaks

• 963 people ill

• 94 Hospitalized

Disease Outbreaks in Treated WaterReported by CDC 2013-2014, Hlavsa 2018

Group Species Outbreaks Cases Hospital

Chemical 13 262 10

Bacteria Pseudomonas aeruginosa 4 12 0

Salmonella 1 5 2

Shigella sonnei 1 6 0

Mycobacterium abscessus 1 11 0

Legionella spp. 18 72 36

Parasites Cryptosporidium spp. 29 543 44

Giardia 1 3 0

Viruses Norovirus 2 34 0

Recreational Water OutbreaksAcute gastrointestinal illness: United States, 2013-2104

Cryptosporidium, 80%

Norovirus, 6%

Shigella, 6%

Giardia, 3%

Multiple, 3% Unidentified, 3%

Treated Water (n = 35)

• Aquatic Venue MAHC definition (3.2)

– Aquatic Venue means an artificially constructed structure or modified natural structure where the general public is exposed to water intended for recreational or therapeutic purpose and where the primary intended use is not watering livestock, irrigation, water storage, fishing, or habitat for aquatic life.

• So what about venues with incidental water exposure?

– Water flume ride

– Decorative fountain

• Organisms from patrons (E. coli, Giardia, Cryptosporidium) may be minimized, but others may not (Naeglaria, Legionella, etc.)

• Each jurisdiction will have its own rules and scope

Other Venues

• Primary sanitizer

• Secondary sanitizer

• Remediation procedures

• Training/Policies/Documentation

Pathogen Incidents- Lessons LearnedHow issues are addressed in the MAHC

Concentration x Time = CT

• Usually 3 log (99.9%) reduction in ppm∙minutes

• Will vary with pathogen strain, temperature, pH, etc.

• Assumed to be linear

If CT = 100 ppm minutes:

• It will take 100 minutes to kill the organism with 1 ppm

or

• It will take 1 minute to kill the organism with 100 ppm

Disinfection Efficacy: CT ValuesMAHC 4.6.2 and 5.6.2

% Removal Log Reduction

Start with 1,000,000 organisms

90% 1 100,000

99% 2 10,000

99.9% 3 1,000

99.99% 4 100

• Common in the environment

• Grows in biofilms

• Spas

– High bather load

– Amplified because Pseudomonas grows well in untreated warm water

• Skin irritation most common effect

– Hot water- dilated pores provide entry route into skin

– Bacteria reproduce in pores and secrete toxins that cause allergic reactions

• Can also cause respiratory and gastrointestinal illness

• Easily controlled with sufficient sanitizer*

– Must maintain at all times to avoid biofilms

Rash outbreaks are an indicator of poor overall sanitation in the facility

* Typical CT = 0.15 ppm-minutes chlorine, Faust & Aly 1998

PseudomonasBacteria

Slide Courtesy of Roy Vore

• Enter pools/spas with fecal material from bathers

• Illness caused by fecal/oral route

• Diarrhea most common effect

• E. coli O157:H7 has caused kidney failure and death in toddlers

• Easily controlled with sufficient sanitizer

– Typical CT = 1-3 ppm-minutes (Block)

E. Coli and ShigellaBacteria

• Found in rivers, shower heads, cooling towers, spas

• Spas are a near-perfect incubator for growing Legionella - warmth, nutrients

• Illness caused by inhalation of Legionella in water droplets

– Pontiac fever most common effect

– Legionnaires disease (pneumonia) - less common but potentially fatal

• Easily controlled with sufficient sanitizer - must maintain at all times to avoid biofilms

– Typical CT = 4 ppm-minutes, Kuchta 1983

LegionellaBacteria

CDC/ Dr. Edwin P. Ewing, Jr.

• Enter pools/spas with vomit and fecal material from bathers

• Illness caused by ingestion - Diarrhea most common effect

• More resistant to chlorine than bacteria

• Typical CT ~ 45 ppm-minutes,

– https://www.cdc.gov/healthywater/swimming/aquatics-professionals/vomit-blood-contamination.html

NorovirusVirus

CDC/ Charles D. Humphrey CDC / Jessica A. Allen

• Enter pools/spas with fecal material from bathers

• Illness caused by fecal/oral route - Diarrhea most common effect

• Comparable to Norovirus in difficulty to kill with chlorine

• Typical CT = 45 ppm-minutes

– https://www.cdc.gov/healthywater/swimming/aquatics-professionals/fecalresponse.html

GiardiaProtozoa

CDC/ Dr. Stan Erlandsen CDC/ Dr. Stan Erlandsen

• C. parvum, C. hominis, others

• Parasite

• Will reproduce in humans and animals

• Will not reproduce in pools and spas

• Tough to kill, CT = 15,300 ppm minutes

• Low infectious dose (10-30 oocysts)

• Excreted weeks after diarrhea ends

CryptosporidiumProtozoa

OocystsSporozoites

Top Photo Credit: H.D.A Lindquist, U.S. EPAReferences: DuPont 1995, Okhuysen 1999, Chappell 1996, Jokipii 1986, Goodgame 1993

• Leaky swim diaper with diarrhea (Amburgey 2011)

– Swim diapers demonstrated 25% - 70% release ofCrypto-sized particles within 2 min.

• Swimmers/Lifeguards with diarrhea

• Animals Ruminants (cows, goats, sheep)

– Birds (possible carriers) (Zhou 2004)

– 23.4% of 209 goose fecal specimens contained crypto.

– 2.4% contained species infectious to humans(C. parvum, C. hominis)

Crypto TransmissionFecal/Oral Route

• Tests conducted with chlorine demand free water with 1 ppm chlorine at pH 7.5, 77° F and in the absence of cyanuric acid.

• These values will be higher in the presence of cyanuric acid.

CT ValuesMAHC A 5.7.3.1.1.2

Organism Time

E. coli O157:H7 Bacterium <1 minute

Hepatitis A Virus About 16 minutes

Giardia Protozoan About 45 minutes

Cryptosporidium Protozoan About 15,300 minutes(10.6 days)

Pathogen Summary

Pathogen Source Illness Reproduction Typical CT

Pseudomonas People and Environment

Rash In water/biofilm <1 ppm min

Legionella Environment Pontiac fever or pneumonia

In water/biofilm 4 ppm min

E. Coli People Diarrhea In people <1 ppm min

Shigella People Diarrhea In people 3 ppm min

Norovirus People Diarrhea In people ~45 ppm min

Giardia People Diarrhea In people ~45 ppm min

Cryptosporidium People Diarrhea In people 15,300 ppm min

• Contamination is inevitable

– Bacteria from environment

– Bacteria, viruses and protozoa from people

• Contamination can be minimized

– Bather hygiene

– Shower before swimming

– Do not swim if ill with diarrhea

– Frequent bathroom breaks

– Diaper changing stations

Pathogen Prevention

Primary Sanitizers

EPA Registered Accepted in APSP-11

Accepted in MAHC

Chlorine √ √ √

Bromine √ √ √

PHMB (biguanide)

√ √

Some metal systems

√ √

Maintain an EPA registered sanitizer residual in all parts of the pool – at all times

• pH

• Ammonia/chloramines

• Cyanuric acid stabilizer

ChlorineFactors that Affect Performance

ChlorinepH Effects

0

20

40

60

80

100

5 6 7 8 9 10pH

Pe

rce

nt

HO

Cl

pH %HOCl

5.0 99.7%

7.0 77.5%

7.5 52.2%

8.0 25.7%

9.5 1.1%

HOCl Hypochlorous acidOCl- Hypochlorite ionH+ Hydrogen ion

• Ammonia (NH3) and other nitrogen based contaminants

o React to form chloramines

o Sources

• Bather waste

• Environment

• Fill water (chloramines)

ChlorineAmmonia Effects

ChlorineAmmonia/Chloramine

Inorganic ChloraminesoIrritantsoSlow disinfection rates

•Monochloramine disinfectant fordrinking water, not for pools

Organic ChloraminesoHuge variety of species

Monochloramine NH2ClDichloramine NHCl2Trichloramine NCl3

Combined chlorine maximum values, ppm

ChlorineAmmonia/Chloramine Recommendations

MAHC APSP-11

Pools 0.4 0.2

Spas 0.4 0.5

Prevention:oBather hygiene

Remedial action:oBreakpoint chlorination (Available chlorine = 10 x combined chlorine)oWater replacement for unreactive species

ChlorineChlorine stabilization with CYA

0

10

20

30

40

50

60

70

80

90

0 10 20 30 40 50 60 70 80 90 100

%C

hlo

rin

e re

mai

nin

g

CYA, ppm

%Chlorine Remaining After 1 Hour Sunlight ExposurePartly cloudy day, 2.5 ppm initial chlorine

(Canelli, 1974)

Cyanuric AcidEffect of CYA on HOCl

pH 7.5, 85 °F, 800 ppm TDS

CYA, ppm

%HOCl for 1 ppm FAC

0 47%

5 13%

10 7%

20 3%

50 1%

Equilibrium constants from O’Brien 1972

Cyanuric acidEffect of CYA on Chlorine Kill Rates

0

1

2

3

4

5

6

7

8

9

0 50 100 150 200 250 300 350 400

CT, p

pm

min

CYA, ppm

Anderson 1965 S. faecalis

Fitzgerald 1967 S. faecalis

Golaszewski 1994 P. aeruginosa

Robinton 1967 E. coli

Robinton 1967 S. faecalis

Robinton 1967 Staph. aureus

Cyanuric AcidContinuous Treatment – Current Recommendations

MAHC

Pools, Max CYA, ppm 90

Spas, therapy pools, Max CYA, ppm 0

Indoor pools, Max, CYA, ppm 0 recommended in Annex

Min chlorine dose, ppm 1 without CYA / 2 with CYA

To prevent exceeding the maximum: Balance use of stabilized and unstabilized chlorine

To lower CYA: Drain

Cyanuric AcidPotential Future Limits for CYA

MAHC = 90 ppm maximumMAHC CYA Ad Hoc Committee (Falk, Blatchley, Suppes, Kuechler, Vore, Pickens, Meyer)

Keep ratio of CYA:Cl constant and the HOCl concentration stays approximately constant

But what ratio should be used?

Using a 15:1 ratio of CYA:FC

Free chlorine, ppm

CYA, ppm HOCl, ppm

1 15 0.0195

2 30 0.0201

4 60 0.0204

6 90 0.0205

8 120 0.0206

10 150 0.0206

pH 7.5, 25 C, 800 ppm TDS

• Using a 15:1 ratio

– If your CYA is 15 ppm, your chlorine must be at least 1 ppm

– If your CYA is 30 ppm, your chlorine must be at least 2 ppm

• EPA maximum for chlorine in pools is 4 ppm. This is federal law.

• CDC maximum for chlorine in pools is 10 ppm. This is a recommendation.

• Local public health codes vary.

Cyanuric AcidHow do you operate off of a ratio?

CYA, ppm FAC Control Range (EPA 4 ppm max limit), ppm

FAC Control Range (CDC 10 ppm max limit), ppm

0 1 ppm min – 4 ppm max 1-10

15 1 ppm min – 4 ppm max 1-10

30 2 ppm min – 4 ppm max 2-10

45 3 ppm min – 4 ppm max 3-10

60 4 ppm min – 4 ppm max 4-10

It is a violation of federal law to use a chlorine sanitizer in a manner inconsistent with its labeling.

Cyanuric AcidCYA Control/Removal - Prevention

Control additions of CYA• Prudent use of CYA• Prudent use of stabilized sanitizers• Use of unstabilized sanitizers

oChlorine gasoLiquid chlorine (sodium hypochlorite)oGranular calcium hypochloriteoSlow dissolve calcium hypochlorite tablets oGranular lithium hypochlorite

Secondary Disinfection

APSP-11 not required

MAHC 4.7.3.3 Requires UV or ozone for• Aquatic venues designed primarily for children under 5 years old

oWading poolsoInteractive water play venues with no standing water

• Therapy pools

MAHC A 4.7.3.3Strongly recommended for all aquatic facilities

• UV light penetrates the cell of the microorganism and disrupts the structure of the DNA molecule prohibiting it from reproducing.

• UV inactivates, it does not “kill”

Secondary DisinfectionUV Dosage

Study Result for UV treatment of crypto

Craik 2001 2-log with 10 mJ/cm2

3-log with 25 mJ/cm2

Linden 2001 ~2-log with 2 mJ/cm2

Hijnen 2006 3-log with <20 mJ/cm2

Belosevic 2001 60 mJ/cm2 with no reactivation

Secondary DisinfectionUV issues and Interferences

EPA 815-R-06-007 Ultraviolet disinfection guidance manual

IssuesNeed dose verification (initial and ongoing with age)Mercury contamination from lamp breakage

oAppendix E EPA 815-R-06-007Effect on Disinfection By-Products (DBP’s) (Weng 2012)

oDecrease in inorganic chloraminesoIncrease in some organic chloramines in presence of chlorine

•Dichloromethylamine, dichloroacetonitrile, cyanogen chlorideInterferences

Humic substances, algaeTurbidityFouling (scale)Chemicals (ozone, iron, permanganate, hydrogen peroxide, hypochlorite, zinc)

• Ozone oxidizes the cell walls, destroying the microorganism

• Study results for ozone with Cryptosporidium parvum

Secondary DisinfectionOzone Dosages

Study CT, ppm min (log reduction)

Korich 1990 5-10 (2 log)

Peeters 1989 6.7-18 (2 log)

Donofrio 2013 1.52 (1.3 to >3 log)

Interferences

• Ozone demand from other oxidizable substances (May reduce chlorine demand)

Issues

• Ozone exposure

o 0.1 ppm maximum in air over water (MAHC 4.7.3.3.4.9)

o Degas and ozone destruct required (MAHC 4.7.3.3.4.4)

• Formation of DBP’s (EPA 815-RR-99-014)

o No Cl, Br present

• Aldehydes, acids

o With Cl, Br present

• Bromate, brominated organics

❑ Not recommended for use with bromine (MAHC A 5.7.3.1.2)

• Chloral hydrate, chloropicrin

Secondary DisinfectionOzone issues and Interferences

• UV and ozone do not have a residual throughout the pool

• Inactivation of organisms is only occurring in the pipe

• They cannot be used for primary disinfection

• You must have a primary disinfectant residual in all parts of the pool at all times

Secondary DisinfectionUV and Ozone Challenges

Secondary DisinfectionIn-Pipe Treatment vs. Whole Pool

Gage-Bidwell: This is the best you can get for in-pipe treatment• Perfect mixing• Treatment of full flow• Log removal in pool using treatments

oWith 1-log, 2-log, 3-log and perfect (∞-log) removals in the pipe

Turnovers 1-log 2-log 3-log ∞-log

0 0 0 0 0

1 0.39 0.43 0.43 0.43

2 0.78 0.86 0.87 0.87

3 1.2 1.3 1.3 1.3

5 2.0 2.1 2.2 2.2

7 2.7 3.0 3.0 3.0

Remedial Treatment Pools – MAHC 6.5

Steps for Remediation• Close pool• Remove fecal material (no vacuum)• pH ≤7.5, temperature ≥77°F• Operating filter while maintaining chlorine• Test for chlorine multiple places• Use only non-stabilized chlorine for

remediation

Remedial Treatment Pools – MAHC 6.5

Additional information for remedial treatment • Use the following CT values

Contaminant Unstabilized Stabilized

Formed stool 50 ppm min(2 ppm 25 min)

100 ppm min(4 ppm 25 min)

Diarrheal stool 15,300 ppm min(20 ppm 12.75 hours)

Lower CYA to ≤15 ppm, and20 ppm for 28 hours30 ppm for 18 hours40 ppm for 8.5 hours

Vomit 50 ppm min 100 ppm min

Blood 0 0

Other options for diarrheal stool

• Circulate through secondary disinfection system to achieve 1 oocyst/100 ml

or

• Drain

Remedial treatment Pools – MAHC 6.5

• Drain all water from spa

• Scrub all surfaces VIGOROUSLY with ≥5 ppm chlorine

• Rinse and flush to waste

• Dispose of filter cartridges/media and replace

• Refill spa with clean water

• Hyperchlorinate with 20 ppm chlorine

o Circulate 1 hour, no jets

o Circulate 9 hours, with jets on

o Maintain 20 ppm through entire treatment

• Flush entire system

http://www.cdc.gov/legionella/downloads/hot-tub-disinfection.pdf

Remedial TreatmentSpas* – CDC

*Now in 2018 MAHC 6.5.3.6

• MAHC 6.3.1.1.2 Qualified operator required on-site or immediately availablewithin 2 hours if

– >2 venues

– >50,000 gallons water

– Aquatic features

– Therapy pool

– Swim training

• MAHC 6.3.4.7.1 Illness policy

• MAHC 6.4.1 Records (operations, illness, water monitoring, remediation, etc.)

• MAHC 6.4.2.2.3 Signage (Do not swim when ill with diarrhea)

–

Training, Policies, Documentation

• Facilities possessing chemicals of interest (COI) must report to DHS within 60 days by filing a Top-Screen survey.

• COI list with threshold quantities– https://www.dhs.gov/appendix-a-chemicals-interest-list

• The Top-Screen survey– https://www.dhs.gov/chemical-security-assessment-tool

• To begin the process of reporting your chemicals of interest, register with DHS.– https://csat-registration.dhs.gov

• DHS chemical security web site is – https://www.dhs.gov/critical-infrastructure-chemical-security

Department of Homeland Security (DHS)Chemical Facility Anti-terrorism Standards (CFATS)

• Hydrochloric acid (conc. 37% or greater) – Thief – 15,000 lbs (~1,800 gallons)

• Chlorine gas –– Release - 2,500 lbs and Thief- 500 lbs

• Chlorine dioxide– Release – 1,000 lbs and Thief – Placarded amount

• Hydrogen peroxide (>35% concentration)– Thief – 400 lbs

• Potassium permanganate– Thief – 400 lbs

Chemicals of Interest (COI)Screening Threshold Quantities

• Centers for Disease Control and Prevention (CDC)– http://www.cdc.gov/healthyswimming/

– http://www.cmahc.org/index.php

• Association of Pool and Spa Professionals– ANSI/APSP-11 2009 American National Standard for Water Quality in Public Pools and Spas

– Information bulletins on pathogens, contamination response, sanitizers

– Standards

– http://www.apsp.org

• World Health Organization Guidelines– http://www.who.int/water_sanitation_health/publications/safe-recreational-water-guidelines-2/en/

• Environmental Protection Agency (EPA)– EPA Registrations

– Label images http://oaspub.epa.gov/pestlabl/ppls.home

– EPA, Alternative Disinfectants and Oxidants Guidance Manual, EPA 815-R-99-014, April 1999

– EPA 815-R-06-007 Ultraviolet disinfection guidance manual for the final long term 2 enhanced surface water treatment rule, 2006

– EPA LT1ESWTR Disinfection Profiling and Benchmarking, 2003 EPA 816-R-03-004

Sources and References

• Barwick, R.S., Levy, D.A., Craun, G.F., Beach, M.J., Calderon, R.L., Surveillance for waterborne disease outbreaks – United States, 1997 – 1998. MMWR Surveill Summ 2000; 49:1-35.

• CDC. Ocular and respiratory illness associated with an indoor swimming pool — Nebraska, 2006. MMWR Morb Mortal WklyRep. 2007;56(36):929-932.

• CDC. Surveillance for waterborne disease and outbreaks associated with recreational water use and other aquatic facility-associated health events--United States, 2005-2006. MMWR Surveill Summ 2008;57:1-29.

• CDC. Respiratory and ocular symptoms among employees of a hotel indoor waterpark resort — Ohio, 2007. MMWR MorbMortal Wkly Rep. 2009;58(4):81-85.

• CDC. Acute illness and injury from swimming pool disinfectants and other chemicals — United States, 2002-2008. MMWR MorbMortal Wkly Rep. 2011;60(39):1343-7.

• Chen L, Dang B, Mueller C, Dunn KH, Almaguer D, Ernst JL, Otto III CS. Health hazard evaluation report: investigation of employee symptoms at an indoor waterpark — Ohio, 2007.[PDF – 64 pages] National Institute for Occupational Safety and Health. 2008; June: HETA 2007-0163-3062.

Sources and References

• Dziuban EJ, Liang JL, Craun GF, et al. Surveillance for waterborne disease and outbreaks associated with recreational water—United States, 2003–2004. In: Surveillance Summaries, December 22, 2006. MMWR 2006;55:1–30.

• News 10 NBC, Posted 9-30-14, $5M settlement for victims of 2005 outbreak at Geneva spray park, http://www.mpnnow.com/article/20140930/News/140939967.

• Smith, S.S. et al. 2015, Legionellosis outbreak associated with a hotel fountain, Open Forum Infectious Diseases, DOI: 10.1093/ofid/ofv164.

• Smith, M., 2012, 3rd Death tied to Chicago Legionnaires’ outbeak, Chicago Tribune Reporter, August 31, 2012.

• Wheeler C, Vugia DJ, Thomas G, Beach MJ, Carnes S, Maier T, Gorman J, Xiao L, Arrowood MJ, Gilliss D, Werner SB. Outbreak of cryptosporidiosis at a California waterpark: employee and patron roles and the long road towards prevention, Epidemiol Infect. 2007 Feb;135(2):302-10.

• Wilken JA, DiMaggio M, Kaufmann M, O’Connor K, Smorodinsky, S, Armatas C, Barreau T, Kreutzer R, Ancheta L. Inhalational chlorine injuries at public aquatic venues — California, 2008–2015. MMWR Morb Mortal Wkly Rep. 2017;66:498–501.

Sources and References

• Amburgey, J.E., and J.B. Anderson. (2011). Disposable Swim Diaper Retention of Cryptosporidium-sized Particles on Human Subjects in a Recreational Water Setting. Journal of Water and Health. 9(4): 653-658.

• Anderson JR. A study of the influence of cyanuric acid on the bactericidal effectiveness of chlorine. Am J Public Health NationsHealth. 1965 Oct;55(10):1629-37.

• Belosevic, FEMS Microbiol Lett. 2001, 204(1) 197-203.

• Block, S. S., Disinfection, Sterilization, and Preservation, 5th Edition, Lippincott Williams and Wilkins, New York, 2001.

• Campbell, A.T. et al. 1995. Inactivation of oocysts of Cryptosporidium parvum by Ultraviolet radiation, Water Research, 29(11), 2583.

• Canelli, E.D., Chemical, bacterillogical, and toxicological properties of cyanuric acid and chlorinated isocyanurates as applied to swimming pool disinfection, a review, AJPH February 1974, 64(2) 155-162.

• Chappell CL, Okhuysen PC, Sterling CR, DuPont HL. Cryptosporidium parvum: intensity of infection and oocyst excretion patterns in healthy volunteers. J Infect Dis 1996;173:232--6.

• Clancy, J.L., Hargy, T. M., Marshall, M. M., Dyksen, J. E. 1997, Inactivation of Cryptosporidium parvum oocysts in water using ultraviolet light, Conference proceedings, AWWA International Symposium on Cryptosporidium and Cryptosporidiosis, Newport Beach, CA.

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