he kiddie pool at Six Flags White Water in Atlanta seemed like a safe enough place for 2-year-old McCall Akin and her mother to cool off on a hot day. Frequented by many toddlers such as herself, its shallow blue basin was carefully watched by lifeguards. But no lifeguard could save McCall from what was about to happen to her that summer of 1998.

A few days later, she started having severe nausea and stomach cramping. Her parents rushed her to the hospital, where she suffered from a stroke and several seizures before slipping into a coma. A few weeks later, she died.

The culprit? A bacteria known as E. coli that health officials later learned McCall ingested while splashing around in the kiddie pool. Over the next two weeks, 25 other children were infected in the same kiddie pool. Seven suffered from kidney failure. Health officials believe the pool was contaminated more than once, since the incidences were clustered over two different weeks, according to expert testimony and news reports.

The outbreak prompted the waterpark, which declined to comment for this article, to install a computerized, 24-hour chlorine-level monitoring device and to require children in kiddie pools to wear sealed plastic pants. No problems have occurred since, say public health officials and experts who investigated and consulted after the incident.

But nothing the waterpark could do would bring back 2-year-old McCall.

And while her story is rare, the incident is not. Cases of recreational water illnesses, or RWIs, contracted within a swimming or spa area have spiked in recent years, according to statistics from the Centers for Disease Control and Prevention in Atlanta. The CDC, which is the only organization that tracks RWIs, keeps statistics in two-year cycles.

In 1991-1992, it recorded 39 total outbreaks that made 1,825 people sick. Only three were associated with a pool. By 2001-2002, the numbers jumped to 65 total outbreaks that made 2,536 people sick. Swimming pools were the site of 44 of those outbreaks. All told, it was the largest number of RWIs reported since the CDC started tracking them in 1978.

More ominously, hospitalizations and deaths have increased in the last several years. During 1991-1992, 21 cases of RWIs resulted in hospitalization and six deaths. By 2001-2002, the most recent statistics available, those numbers had jumped to 61 hospitalizations and eight deaths.

Even those numbers are artificially low, says Dr. Michael Beach, an epidemiologist with the CDC’s Division of Parasitic Diseases. Because the symptoms are often minor — anything from diarrhea to stomach cramps to rashes — many people don’t even know they have contracted a recreational water illness, and it never gets reported.

But that’s changing. Thanks to educational efforts by the CDC and the aquatics industry, more people are aware of RWIs. And that in itself may be part of the reason for the increase in reported cases — as more people become aware of them, more report them.

But that’s not the only reason, warn experts. They say part of the problem may be related to the changing nature of aquatics venues. Shallow water pools, waterparks and spray pads draw larger crowds — and become prime breeding ground for bacteria and other water-borne diseases when bather loads get too high.

Shrinking budgets also mean smaller staffs, and less professionals to police water chemistry. Many people who operate pools still are not trained in maintaining proper water chemistry. And experts contend that many health codes are too antiquated.

No matter the reason for the mounting number of outbreaks, every time someone gets sick or dies from an RWI, it leaves a black mark on facilities and the aquatics industry as a whole. Experts warn that unless the industry cleans up its act, that mark could become a permanent deterrent to all things aquatic.

The Nature of RWIs
Recreational water illnesses occur when a pool or spa becomes contaminated by a bacteria or parasite and infects a swimmer. They fall into two categories: endemic — when one person becomes infected; and epidemic — when two or more people become ill at the same time with similar symptoms.

An outbreak occurs when the bacteria or parasite infects at least one person. But an epidemic case is usually what’s reported, says Kent Williams, executive director of the Professional Pool Operators of America in Newcastle, Calif.

“If it’s one person you can’t suspect the pool,” he says. “If two or more members of a swim team get the same problem, we have to suspect the pool.”

The CDC agrees. Beach says more and more RWIs are happening in swimming pools than ever before. For instance, RWI reports generally peak during popular swimming seasons, from early summer to early fall. Most — 32 percent in 2001-2002 — are related to a relatively minor skin rash known as pseudomonas dermatitis. But others have more serious consequences. For instance, cryptosporidium, a particularly chlorine-resistant parasite that causes diarrhea, stomach cramps, fever and nausea, accounts for nearly 70 percent of the diarrheal outbreaks in treated venues. In 2001-2002, nine of the 11 cases of crypto were traced back to wading and swimming pools, according to Beach.

Swimming in Sewers?
So why are RWIs becoming more prominent in the aquatic world? Experts cite many reasons, ranging from hygiene habits to higher bather loads.

But they all lead back to the same thing: improper water maintenance.

“We have a problem,” says Alison Osinski, president of Aquatic Consulting Services in San Diego. “Codes are out-of-date. There are myths and bad practices. The Germans say, ‘you Americans swim in sewers.’ ”

Osinski also believes much of the problem stems from a combination of more people visiting aquatics facilities and the trends in swimming pool design. Shallower, smaller wading pools are replacing the traditional large-volume rectangular lap lane pool, changing the bather load/water volume ratio. Waterpark pools are prime examples of such high-density loads. With more people frolicking in 18 inches of water, rather than in 3 to 5 feet of water in a traditional pool, RWIs are more likely to take hold.

Another reason for an increase in RWI reports is the detection of formerly unknown diseases that are resistant to chlorine, experts say.

For instance, some bacteria live in a tough biofilm that protects them from sanitizers and other conditions, says Suzy Campbell, senior environmental specialist for the Oklahoma City County Health Department. The biofilm can live on the underside of a skimmer lid, which needs to be scrubbed with environmental cleaners to kill it.

Others, such as cryptosporidium, are highly resistant to chlorine and have only recently been discovered. With its highly impenetrable shell, cryptosporidium can linger in a chlorinated pool for up to a week before being killed. Its appearance at the Mustang Water Slides in Arroyo Grande, Calif., last summer caused more than 250 cases of illnesses and closed the park’s doors for the rest of the season.

Similarly, giardia, another parasite, takes up to 45 minutes to be destroyed in chlorine. The origins of an outbreak caused by giardia were traced back to the children’s pool at the Wollaston Golf Club in Milton, Mass., in 2003. At least 55 people were infected. Norovirus is a virus that takes about 30 to 60 minutes to become deactivated in a normal chlorinated pool. In 2002, 36 people became ill from swimming in a Minnesota hotel pool infected with the virus. All three diseases are introduced through fecal matter.

Years ago, such incidents might not even have been reported. But today, facilities and the public are reporting more cases of RWIs, and awareness is on the rise.

“I don’t think it happens more,” says Campbell. “I think we’re better at detecting it.”

Anita Highsmith agrees. “We’re a much more savvy population than we have been in the past,” says the principal of Highsmith Environmental Consulting in Atlanta. “When something occurs in the form of a disease, people are more likely to report it.”

The CDC has also been stepping up its efforts to confront the issue. For instance, it’s attempting to set up a national strategic plan to address the growing threat of RWIs in aquatics. Not coincidentally, that comes on the heels of a report released in June 2003, in which more than half of the 22,000 public pools inspected were in violation of public health codes. Water quality was so poor in about eight percent of the pools that officials required immediate closure. The majority of the violations resulted from improper chlorine and pH levels, with problems in filtration and recirculation systems coming in second — all of which could lead to RWIs.

Finally, experts say the hygiene of pool patrons is lacking. “The days of seeing people take hot soapy showers [before swimming] are long gone,” Osinski says. “People are walking around tracking everything in on the decks, and deck maintenance is not keeping up.”

Other issues of hygiene include parents who change diapers by the poolside and rinse the baby off with pool water, or people who don’t wash their hands after using the restroom and entering the pool. Most troublesome, experts say, are people who still go swimming or take a child swimming with diarrhea. And although signs are posted, experts agree that most patrons ignore them.

Experts say a common public misperception is that chlorine will automatically kill everything in a pool, keeping swimmers safe. “The public needs to be informed,” Beach says. “We’re not swimming in sterile drinking water.”

An Industry Illness
Of course, the industry has to walk a fine line between scaring people about RWIs and keeping them coming back to pools and waterparks. But having an outbreak is far worse than confronting patrons with the facts about RWIs.

“[Closing a facility] would put many institutional and municipal pools in near bankruptcy,” Williams says. “It would put a waterpark out of business.”

And no matter where an outbreak occurs, news of it is bad PR for the aquatics world.

“People who get severe stomachaches and diarrhea [from swimming] are not going to be poster children for pools and spas,” says Tom Lachocki, president of the National Swimming Pool Foundation in Colorado Springs, Colo. “The negative effects really limit our ability to get more people.”

Conversely, facilities that show patrons they are up to and beyond water safety standards will have an edge. “The message has to be clear to the person who’s going to the pool that the sanitary standards of the facility are exceptional,” Lachocki says.

A facility in Lawrence, Kan., was up to the challenge. A cryptosporidium outbreak in the county caused 100 confirmed cases and possibly hundreds more. Authorities immediately suspected city and apartment pools, says Mark Hecker, the city’s superintendent of parks and facilities. But Hecker’s indoor pool had a rock solid alibi: an ultraviolet system that zaps cryptosporidium instantaneously.

Williams says all facilities should offer those kinds of assurances. He recommends displaying badges of certification and training in water chemistry and maintenance. Keeping the facility exceptionally clean will also convey a sparkling image to the public.

The Best Medicine
But efforts need to be more than cosmetic if the industry hopes to win the battle against RWIs, warns Beach. Pools need to be brought up to code. Facilities with kiddie pools should have their filtration systems examined. Increasing water turnover rates in wading pools, for instance, can decrease the amount of exposure time to potential diseases. Considering new methods of water treatment, including ozone and UV, are other possibilities.

Next, operators need to be trained properly to recognize how to follow such guidelines and enforce them. Osinski points out that anybody can be an operator, with or without credentials.

A recent CDC report showed that one in four pool operators were not trained.

“Before we look at how they can be trained better, first and foremost is to make sure they are trained,” Lachocki says.

Operators and managers should build relationships with local health officials and train their staff appropriately. Lachocki recommends expanding pool operation knowledge by attending trade shows and urges operators to review certification handbooks regularly.

Educating swimmers is the next step.

Lachocki says targeting season pass holders is a good place to start. Handing out reading materials and brochures along with park information, and giving a first-time user a facility tour that addresses RWI issues will increase awareness. Their behavior will in turn set an example for day visitors. Posting attractive signs and having lifeguards reiterate those messages will help spread the word.

Finally, aggressive attention to the health of the pool is vital. Experts advise checking chlorine and pH levels more than required. And definitely more than once a day.

“I always say swimming at eight in the morning is the safest time, because they test once a day,” says John Falik, CEO and owner of Poolsure in Houston. Falik’s company supplies a detection system and chemicals to commercial pools throughout Florida and Texas, alerting a facility if its chemical readings drop below the right amount. “[Chlorine levels are] being driven down to zero during the day,” he says.

Williams says such prevention measures can help reduce outbreaks. But he and others say they will continue to occur until the industry takes water maintenance more seriously.

“Attitude, attention and focus will change things completely,” he says. “The procedure really makes things happen.”

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