Recreational Waterborne Illnesses: Recognition, Treatment, and Prevention

 

Am Fam Physician. 2017 May 1;95(9):554-560.

Patient information: See related handout on waterborne illnesses, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Illness after recreational water activities can be caused by a variety of agents, including bacteria, viruses, parasites, algae, and even chlorine gas. These illnesses are more common in summer. Waterborne illnesses are underreported because most recreational activity occurs in unsupervised venues or on private property, and participants tend to disperse before illness occurs. Symptoms of waterborne illness are primarily gastrointestinal, but upper respiratory and skin manifestations also occur. Gastrointestinal symptoms are usually self-limited, and supportive treatment may be all that is necessary. However, some infections can cause significant morbidity and mortality. Cryptosporidium and Giardia intestinalis are the most common cause of gastrointestinal illness and have partial chlorine resistance. Respiratory infections are typically mild and self-limited. However, if legionnaires' disease develops and is unrecognized, mortality may be as high as 10%. Cellulitis caused by Vibrio vulnificus can result in serious illness, amputation, and death. Early and appropriate antibiotic treatment is important. Chronically ill and immunocompromised persons are at high risk of infection and should be counseled accordingly.

Approximately 40% of Americans swim recreationally, and many others have limited contact with water recreationally through canoeing and other activities.1 Outdoor recreation of any type puts persons at risk of sunburn, injuries, and infections due to incidental human contact. The presence of water adds the possibility of drowning or near drowning, with 3,300 deaths and another 5,000 hospitalizations annually.2 Additionally, a growing number of persons become ill from exposure to tainted water, whether from ingestion or other means. Man-made changes to the environment plus introduction of exotic species may increase the risk of infection.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Clinicians should obtain an exposure history in patients presenting with symptoms that may be linked to waterborne illness, especially in the summer.

C

3

Persons with prolonged or recurrent diarrhea with potential exposure history should be tested for Giardia infection.

C

8

Patients with open wounds, diabetes mellitus, or chronic liver conditions should avoid swimming in brackish water because of the high risk of Vibrio vulnificus infection.

C

30, 31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Clinicians should obtain an exposure history in patients presenting with symptoms that may be linked to waterborne illness, especially in the summer.

C

3

Persons with prolonged or recurrent diarrhea with potential exposure history should be tested for Giardia infection.

C

8

Patients with open wounds, diabetes mellitus, or chronic liver conditions should avoid swimming in brackish water because of the high risk of Vibrio vulnificus infection.

C

30, 31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The Centers for Disease Control and Prevention (CDC) recently began tracking multiperson outbreaks associated with recreational waterborne activities. These data are voluntarily reported from all 50 states and U.S. territories. Annually, at least 2,000 persons contract disease in this manner, with about 10% of cases resulting in hospitalization.3 Although untreated ponds and rivers are often thought to be the culprit, a public pool or hot tub is more often the source.3 The incidence is higher in the summer because of increased recreational exposure (Figure 1).4 The true incidence is likely underreported because these illnesses tend to be self-limited, most recreational activity is on private property, and swimmers tend to disperse after exposure. The most common manifestation is gastrointestinal, but there are agents that cause pulmonary and skin manifestations as well. The symptoms are not specific to waterborne illnesses; waterborne pathogens should be suspected if symptoms coincide with water-based activity, especially in the summer.3  Table 1 identifies the most common symptoms of waterborne illness, initial management, and symptoms that require urgent disease-specific treatment in addition to supportive care.512

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Multiperson outbreaks of recreational waterborne illness by month and type, 2011 to 2012.

Figure 1.

Reprinted from Centers for Disease Control and Prevention. Waterborne disease and outbreak surveillance

The Authors

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ALLEN PERKINS, MD, is a professor in the Department of Family Medicine at the University of South Alabama College of Medicine, Mobile....

MARIROSE TRIMMIER, MD, is an assistant professor in the Department of Family Medicine at the University of South Alabama College of Medicine, Mobile.

Address correspondence to Allen Perkins, MD, University of South Alabama, 1504 Springhill Ave., Ste. 3414, Mobile, AL 36604 (e-mail: perkins@health.southalabama.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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