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Hygiene for hydrotherapy pools
Journal of Hospital Infection (1986) 8, 213-216
LEADING
Hygiene
ARTICLE
for hydrotherapy
pools
The role of recreational pools, especially the whirlpool or ‘Jacuzzi’, as a potential source of human infection has been reviewed recently (Brett & Du Vivier, 1985; Jones & Bartlett, 1985; Ratman et al., 1986). A variety of micro-organisms have been implicated including mycobacteria (Kirk 8z Kaminski, 1976), legionella, and adenoviruses (Schmidt et al., 1975). Free living amoebae, transmitted by nasal inoculation, have potential for transmission although not yet reported in association with whirlpools. The commonest infection is, however, with Pseudomonas aeruginosa-one outbreak associated with a waterslide involved 2.56 cases (Perrotta et al., 1983). Survival of pseudomonas and other water organisms in pools containing chemical germicides seems to be aided by the development of a protective glycocalyx (Favero, 1984). Bacterial multiplication to critical levels usually follows a breakdown in disinfection technique, although none of the published reports state the numbers of bacteria found in whirlpools at the time of infection. Otitis externa (Reid & Porter, 1981; Havelaar, Bosman & Borst, 1983), and outbreaks of a characteristic skin rash or folliculitis (Gustafson et al., 1983) are the commonest reported clinical sequelae of Ps. aeruginosa infection, which is usually with Habs serotype 11 strains. Serotypes 6 and 11 are however the two commonest strains found in hospitals. Isolated cases of pneumonia (Rose et al., 1983) and urinary tract have also been infection (Salmen et al., 1983) from home installations described. The latter authors highlight the potential problems: ‘The spa was located in a newly purchased home and had been filled with water but not used for one month before the two patients were exposed; it did not contain a functioning filter, and had only intermittently been chlorinated’. Cultures even after further chlorination yielded 9-O X lo4 cfu 1-l of Ps. aeruginosa. The hospital hydrotherapy pool differs from a normal swimming bath. It is used by both inpatients and outpatients, and the staff may be immersed for fairly long periods. The high operating temperature accelerates the breakdown of disinfectants and may encourage microbial growth. Certain types of patient, such as those with cystic fibrosis, may be highly susceptible to infections; while others may contaminate the pool and even defaecate on occasion. Staff are hopefully healthy and the hazards to them seem more to be chemical and perhaps to affect the swimming costume (bleach) more than the wearer. The isolation of Mycobacterium chelonei from the sputum of three children with cystic fibrosis was recently reported to the Communicable 0195-6701/86/0602l3+04
$03.09/0
0 1986 The Hospital
213
Infection
Society
214
P. A. Friend
and S. W. B. Newson
Diseases Surveillance Centre [CDSC] following use of a pool in Hampshire. No ill effect was observed although mycobacterial infection can cause significant illness in cystic fibrosis patients. A recent experience at a local district general hospital demonstrates a further hazard of chest infection. Two young patients with cystic fibrosis simultaneously acquired infection with a serotype 10 strain of Ps. aeruginosa following swimming lessons in the hydrotherapy pool. Subsequent examination of pool water revealed >lO”cfuml-’ of pseudomonads with smaller numbers, about 20 ml-‘, of the infecting serotype. The report of the Central Sterilising Club working party on hydrotherapy pools (McDougall et al., 1986) confirmed suspicions that few hospitals had adequate pool handling protocols, and provides an invaluable bench book for staff operating pools. The report recommends a ‘management structure’. Day to day running should be dealt with by a local team consisting of a named physiotherapist and dedicated engineer, with the back up of the microbiologist or infection control nurse where appropriate. Policy should be laid down by a district based team consisting of the district senior physiotherapist, an engineer, the microbiologist, and an administrator (or one from each hospital with a hydrotherapy pool if relevant). A national reference centre for problems associated with pools is obviously a useful facility; the Communicable Disease Surveillance Centre is prepared to do this, and seems the right place for it. The report deals with the ‘Treatment and quality of hydrotherapy pool water’, ‘Patient hygiene and safety’, ‘Pool area hygiene’, and ‘Systematic monitoring’. A list of experts, details of disinfectant preparation, and a prototype record chart for pool monitoring are provided as appendices. Chlorine is the disinfectant of choice either as sodium hypochlorite or a chlorinated isocyanurate, although calcium hypochlorite can be used. A polymeric biguanide is less easy to use and more expensive, qualities shared by bromine based disinfectants which can be associated with skin rashes and so are not recommended. Misuse of chlorine can cause problems too, notably when insufficient free chlorine is maintained in the presence of excess organic contamination. The number of hydrotherapy pools in National Health Service hospitals has increased considerably recently, furthermore the provision of on-site staff social clubs may include swimming pools. This presents the microbiologist with a potential problem which may have appeared in a ‘silent’ manner, without previous consultation. If so what microbiological monitoring is being performed-possibly none. What should be done? The report noted that ‘although not contributing to daily control, periodic bacteriological examinations provide valuable data not found in the chemical or physical tests’ and suggests twice weekly tests. The standard Escherichia coli count for potable water is clearly irrelevant ‘although
Hygiene
for hydrotherapy
pools
215
accompanied by a mythical aura of traditional merit’. Total counts of after 24 h incubation at 37°C are a signal for further >lOOcfuml-’ investigation especially if es. aeruginosa is present. The principles in the report apply equally well to ‘Jacuzzis’ and whirlpools. Spas are dealt with in the Swimming Pool and Allied Trades Association (SPATA) Standards for Commercial Spas (1986), chapter 8 of which deals with ‘Installation, Chemicals and Water Treatments’. This document somewhat complements the previous one, with details of installers responsibility, standards for fill water, and use water, together with detailed instructions for handling and storing chemicals. The same biological standards are recommended, but their application is left open at the judgement of the local environmental health officer. While the twice weekly recommendation may seem excessive, this one is too loose, and a test frequency should be laid down. Details of disinfectants are given, although as is usual for a standard no preference is stated, and indeed a specific disclaimer is included. In addition to halogens, the use of ozone is mentioned. This has however to be supplemented by a secondary disinfectant once the water is in the spa. A recent development is use of ozone plus sodium bromide to release bromine into the water. The standard is of little help in day to day running of spas, but will be useful for defining policy, and taken together with the Central Sterilising Club report provides useful data of a kind not readily available elsewhere. Department of Bacteriology Addenbrookes Hospital Cambridge CB2 2QQ
P. A. Friend S. W. B. Newsom
References Brett.
I. & Du Vivier. A. (1985). Pseudomonas aeruginosa and whirlpools. British iedical journal 290, 102L102‘5. ’ Favero. M. S. (1984). Whirlnool soa-associated infections: are we really in hot water? American Journal of Public Heaith 74, 653-655. Gustafson, T. L., Band, J. D., Hutcheson, R. H. & Schaffner, W. (1983). Pseudomonas folliculitis: An outbreak and review Reviews of Infectious Diseases 5, l-8. Havelaar, A. H., Bosman, M. & Borst, J. (1983). Otitis externa caused by Pseudomonas aeruginosa associated with whirlpools. Journal of Hygiene 90, 489498. Jones, F. & Bartlett, C. R. (1985). Infections associated with whirlpools and spas. In Microbial Aspects of Water Management (White, W. R. & Passmore, S., Eds). Journal of Applied Bacteriology 59, Suppl. p. 61 S-67s. Kirk, J. & Kaminski, G. W. (1976). Mycobacterium marinum infection. AustralianJournal of Dermatology 17, 111-l 16. McDougall, S. M., Delpak, Kathryn, Mann, P., Mahoney, Mary, C. & Penny, P. (1986). Hygiene for Hydrotherapy Pools. Central Sterilising Club, Report No. 3. Perrotta, D. M., Johns, R. E., Bradley, R., Jacobson, J., Miner, K., Sadler, T. & Gibbons, H. L. (1983). An outbreak of pseudomonas folliculitis associated with a water slide. Journal of the American Medical Association 250, 1259.
216
P. A. Friend
and S. W. B. Newson
Ratman, S., Hogan, K., March, S. B. & Butler, R. W. (1986). Whirlpool associated folliculitis caused by Pseudomonas aeruginosa; Report of an outbreak and review. Journal of Clinical Microbiology 23, 655-659. Reid, T. M. S. & Porter, I. A. (1981). An outbreak of otitis externa in competitive swimmers. Journal of Hygiene 86, 357-361. Rose, H. D., Franson, T. R., Sheth, N. K., Chusid, M. J., Macher, A. M. & Zeirdt, C. H. (1983). Pseudomonas pneumonia associated with use of a home whirlpool spa.Journal of the American Medical Association 250, 2027-2029. Salmen, P., Dwyer, D. M., Vorse, H. & Kruse, W. (1983). Whirlpool associated Pseudomonas aeruginosa urinary tract infections. Journal of the American Medical Association 250, 2025-2026. virus in adenovirus Schmidt, 0. W., Cooney, M. K., Foy, H. M. (1975). Ad eno-associated 11, 1362-1370. type 3 conjunctivitis. Infection and Immunity SPATA (1986). Standards for Commercial Spas. SPATA, Caterham, U.K.
LEADING
Hygiene
ARTICLE
for hydrotherapy
pools
The role of recreational pools, especially the whirlpool or ‘Jacuzzi’, as a potential source of human infection has been reviewed recently (Brett & Du Vivier, 1985; Jones & Bartlett, 1985; Ratman et al., 1986). A variety of micro-organisms have been implicated including mycobacteria (Kirk 8z Kaminski, 1976), legionella, and adenoviruses (Schmidt et al., 1975). Free living amoebae, transmitted by nasal inoculation, have potential for transmission although not yet reported in association with whirlpools. The commonest infection is, however, with Pseudomonas aeruginosa-one outbreak associated with a waterslide involved 2.56 cases (Perrotta et al., 1983). Survival of pseudomonas and other water organisms in pools containing chemical germicides seems to be aided by the development of a protective glycocalyx (Favero, 1984). Bacterial multiplication to critical levels usually follows a breakdown in disinfection technique, although none of the published reports state the numbers of bacteria found in whirlpools at the time of infection. Otitis externa (Reid & Porter, 1981; Havelaar, Bosman & Borst, 1983), and outbreaks of a characteristic skin rash or folliculitis (Gustafson et al., 1983) are the commonest reported clinical sequelae of Ps. aeruginosa infection, which is usually with Habs serotype 11 strains. Serotypes 6 and 11 are however the two commonest strains found in hospitals. Isolated cases of pneumonia (Rose et al., 1983) and urinary tract have also been infection (Salmen et al., 1983) from home installations described. The latter authors highlight the potential problems: ‘The spa was located in a newly purchased home and had been filled with water but not used for one month before the two patients were exposed; it did not contain a functioning filter, and had only intermittently been chlorinated’. Cultures even after further chlorination yielded 9-O X lo4 cfu 1-l of Ps. aeruginosa. The hospital hydrotherapy pool differs from a normal swimming bath. It is used by both inpatients and outpatients, and the staff may be immersed for fairly long periods. The high operating temperature accelerates the breakdown of disinfectants and may encourage microbial growth. Certain types of patient, such as those with cystic fibrosis, may be highly susceptible to infections; while others may contaminate the pool and even defaecate on occasion. Staff are hopefully healthy and the hazards to them seem more to be chemical and perhaps to affect the swimming costume (bleach) more than the wearer. The isolation of Mycobacterium chelonei from the sputum of three children with cystic fibrosis was recently reported to the Communicable 0195-6701/86/0602l3+04
$03.09/0
0 1986 The Hospital
213
Infection
Society
214
P. A. Friend
and S. W. B. Newson
Diseases Surveillance Centre [CDSC] following use of a pool in Hampshire. No ill effect was observed although mycobacterial infection can cause significant illness in cystic fibrosis patients. A recent experience at a local district general hospital demonstrates a further hazard of chest infection. Two young patients with cystic fibrosis simultaneously acquired infection with a serotype 10 strain of Ps. aeruginosa following swimming lessons in the hydrotherapy pool. Subsequent examination of pool water revealed >lO”cfuml-’ of pseudomonads with smaller numbers, about 20 ml-‘, of the infecting serotype. The report of the Central Sterilising Club working party on hydrotherapy pools (McDougall et al., 1986) confirmed suspicions that few hospitals had adequate pool handling protocols, and provides an invaluable bench book for staff operating pools. The report recommends a ‘management structure’. Day to day running should be dealt with by a local team consisting of a named physiotherapist and dedicated engineer, with the back up of the microbiologist or infection control nurse where appropriate. Policy should be laid down by a district based team consisting of the district senior physiotherapist, an engineer, the microbiologist, and an administrator (or one from each hospital with a hydrotherapy pool if relevant). A national reference centre for problems associated with pools is obviously a useful facility; the Communicable Disease Surveillance Centre is prepared to do this, and seems the right place for it. The report deals with the ‘Treatment and quality of hydrotherapy pool water’, ‘Patient hygiene and safety’, ‘Pool area hygiene’, and ‘Systematic monitoring’. A list of experts, details of disinfectant preparation, and a prototype record chart for pool monitoring are provided as appendices. Chlorine is the disinfectant of choice either as sodium hypochlorite or a chlorinated isocyanurate, although calcium hypochlorite can be used. A polymeric biguanide is less easy to use and more expensive, qualities shared by bromine based disinfectants which can be associated with skin rashes and so are not recommended. Misuse of chlorine can cause problems too, notably when insufficient free chlorine is maintained in the presence of excess organic contamination. The number of hydrotherapy pools in National Health Service hospitals has increased considerably recently, furthermore the provision of on-site staff social clubs may include swimming pools. This presents the microbiologist with a potential problem which may have appeared in a ‘silent’ manner, without previous consultation. If so what microbiological monitoring is being performed-possibly none. What should be done? The report noted that ‘although not contributing to daily control, periodic bacteriological examinations provide valuable data not found in the chemical or physical tests’ and suggests twice weekly tests. The standard Escherichia coli count for potable water is clearly irrelevant ‘although
Hygiene
for hydrotherapy
pools
215
accompanied by a mythical aura of traditional merit’. Total counts of after 24 h incubation at 37°C are a signal for further >lOOcfuml-’ investigation especially if es. aeruginosa is present. The principles in the report apply equally well to ‘Jacuzzis’ and whirlpools. Spas are dealt with in the Swimming Pool and Allied Trades Association (SPATA) Standards for Commercial Spas (1986), chapter 8 of which deals with ‘Installation, Chemicals and Water Treatments’. This document somewhat complements the previous one, with details of installers responsibility, standards for fill water, and use water, together with detailed instructions for handling and storing chemicals. The same biological standards are recommended, but their application is left open at the judgement of the local environmental health officer. While the twice weekly recommendation may seem excessive, this one is too loose, and a test frequency should be laid down. Details of disinfectants are given, although as is usual for a standard no preference is stated, and indeed a specific disclaimer is included. In addition to halogens, the use of ozone is mentioned. This has however to be supplemented by a secondary disinfectant once the water is in the spa. A recent development is use of ozone plus sodium bromide to release bromine into the water. The standard is of little help in day to day running of spas, but will be useful for defining policy, and taken together with the Central Sterilising Club report provides useful data of a kind not readily available elsewhere. Department of Bacteriology Addenbrookes Hospital Cambridge CB2 2QQ
P. A. Friend S. W. B. Newsom
References Brett.
I. & Du Vivier. A. (1985). Pseudomonas aeruginosa and whirlpools. British iedical journal 290, 102L102‘5. ’ Favero. M. S. (1984). Whirlnool soa-associated infections: are we really in hot water? American Journal of Public Heaith 74, 653-655. Gustafson, T. L., Band, J. D., Hutcheson, R. H. & Schaffner, W. (1983). Pseudomonas folliculitis: An outbreak and review Reviews of Infectious Diseases 5, l-8. Havelaar, A. H., Bosman, M. & Borst, J. (1983). Otitis externa caused by Pseudomonas aeruginosa associated with whirlpools. Journal of Hygiene 90, 489498. Jones, F. & Bartlett, C. R. (1985). Infections associated with whirlpools and spas. In Microbial Aspects of Water Management (White, W. R. & Passmore, S., Eds). Journal of Applied Bacteriology 59, Suppl. p. 61 S-67s. Kirk, J. & Kaminski, G. W. (1976). Mycobacterium marinum infection. AustralianJournal of Dermatology 17, 111-l 16. McDougall, S. M., Delpak, Kathryn, Mann, P., Mahoney, Mary, C. & Penny, P. (1986). Hygiene for Hydrotherapy Pools. Central Sterilising Club, Report No. 3. Perrotta, D. M., Johns, R. E., Bradley, R., Jacobson, J., Miner, K., Sadler, T. & Gibbons, H. L. (1983). An outbreak of pseudomonas folliculitis associated with a water slide. Journal of the American Medical Association 250, 1259.
216
P. A. Friend
and S. W. B. Newson
Ratman, S., Hogan, K., March, S. B. & Butler, R. W. (1986). Whirlpool associated folliculitis caused by Pseudomonas aeruginosa; Report of an outbreak and review. Journal of Clinical Microbiology 23, 655-659. Reid, T. M. S. & Porter, I. A. (1981). An outbreak of otitis externa in competitive swimmers. Journal of Hygiene 86, 357-361. Rose, H. D., Franson, T. R., Sheth, N. K., Chusid, M. J., Macher, A. M. & Zeirdt, C. H. (1983). Pseudomonas pneumonia associated with use of a home whirlpool spa.Journal of the American Medical Association 250, 2027-2029. Salmen, P., Dwyer, D. M., Vorse, H. & Kruse, W. (1983). Whirlpool associated Pseudomonas aeruginosa urinary tract infections. Journal of the American Medical Association 250, 2025-2026. virus in adenovirus Schmidt, 0. W., Cooney, M. K., Foy, H. M. (1975). Ad eno-associated 11, 1362-1370. type 3 conjunctivitis. Infection and Immunity SPATA (1986). Standards for Commercial Spas. SPATA, Caterham, U.K.