Recreational water–related illness

We were delighted to read the article by Sanborn and Takaro (1) on recreational water illness among Canadian primary care patients. We feel it is important that physicians understand that use of recreational water among the public may contribute to a significant burden of gastrointestinal illness in warmer months.

However, for the overall burden of enteric illness in Canada, a convincing body of evidence indicates that food is the most commonly reported probable source, and also has an increased seasonal distribution in the summer (2,3,4). Risks of foodborne illness are also important knowledge for primary care physicians.

The article thoroughly explains risks among users of untreated water sources, such as lakes and beaches. We would also like to highlight that individuals using treated recreational water sources, such as pools and splash pads, may experience an even greater proportion of disease outbreaks (5). Physicians should also ask about these exposures among symptomatic patients, and counsel those who may be at risk.

Further, physicians can also play an important role in counseling patients about personal hygiene before entering a pool setting, and avoidance of these settings if they are ill (6). Both of these steps are essential to maintaining personal and public health while enjoying treated or untreated recreational water this summer.

We agree that encouraging physicians to test stool samples inpatients with severe symptoms will aid in proper diagnosis and treatment in a clinical setting. However, most relevant guidelines (7, 8,9) do not recommend cultures for patients without severe or prolonged course of illness, as it is not cost-effective and does not change management.

Finally, we also wish to highlight the important role that local public health agencies (LPHAs) play in minimizing risk from recreational water exposure through routine inspection and investigation of potentially contaminated sources. We urge family physicians who suspect an infectious recreational hazard to actively contact their LPHA in advance of microbiological proof to mitigate the potential hazard in a timely manner through inspection.

Pamela Leece, MD, MSc, CCFP Nikhil Rajaram, MD, CCFP, MPH

References

(1) Sanborn M, Takaro T. Recreational water-related illness: Office management and prevention. Can Fam Physician. 2013 May;59(5):491-5.

(2) Keegan VA, Majowicz SE, Pearl DL, Marshall BJ, Sittler N, Knowles L, Wilson JB. Epidemiology of enteric disease in C-EnterNet's pilot site - Waterloo region, Ontario, 1990 to 2004. Can J Infect Dis Med Microbiol. 2009 Fall;20(3):79-87.

(3) Rajda Z, Middleton D. Descriptive epidemiology of enteric illness for selected reportable diseases in Ontario, 2003. Can Commun Dis Rep. 2006 Dec 1;32(23):275-85.

(4) Lee MB, Middleton D. Enteric illness in Ontario, Canada, from 1997 to 2001. J Food Prot. 2003 Jun;66(6):953-61.

(5) Centers for Disease Control and Prevention. Surveillance for Waterborne Disease Outbreaks and Other Health Events Associated with Recreational Water -- United States, 2007-2008. MMWR 2011;60 (12): 1-37.

(6) Centers for Disease Control and Prevention. Microbes in Pool Filter Backwash as Evidence of the Need for Improved Swimmer Hygiene - Metro-Atlanta, Georgia 2012. MMWR 2011;62 (19): 385-388.

(7) Guidelines and Protocols Advisory Committee. Infectious Diarrhea - Guideline for Ordering Stool Specimens 2009; Available at: http://www.bcguidelines.ca/pdf/diarrhea.pdf. Accessed 05/29, 2013.

(8) World Gastroenterology Organisation. Acute diarrhea in adults and children: a global perspective . 2012; Available at: http://www.worldgastroenterology.org/assets/export/userfiles/Acute%20Diarrhea_long_FINAL_120604.pdf. Accessed 05/29, 2013.

(9) DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 1997 Nov;92(11):1962-75.

Conflict of Interest:

None declared