SEPA
United States
Environmental Protection
Agency
Health Effects Research
Laboratory
Cincinnati OH 45268
Research and Development
EPA-600/S1-81-059 Sept. 1981
Project Summary
Recreational Water
Quality and Health
R. L. Northrop, G. R. Brenniman, S. H. Rosenberg, R. B. Byington, and C. S
Hesse
The overall objective of this pilot
study was to develop and evaluate
methods to determine the effect of
recreational water quality on the
health of persons bathing in fresh
waters. Little scientific evidence
exists upon which to base water qual-
ity standards for the safety of persons
using fresh waters for primary contact
recreation.
This pilot study was designed to
develop: (1) sampling and recruiting
methodology of families attending
freshwater beaches; (2) survey instru-
ments for telephone interviews to
obtain demographic and socioeco-
nomic information, and the collection
of prospective data regarding health
status of family members; and (3) the
sampling design for the collection of
certain water quality variables in order
to best relate the effect of the recrea-
tional water quality on the health of
persons bathing in those waters.
Results of this study indicate that it
was possible to recruit and follow
families via telephone interviews over
a three-week period with low attrition
rates. A promotional letter used in
conjuction with recruitment had no
positive effect in reducing the attrition
rate.
The demographic characteristics of
bathers and nonbathers at the two
study beaches were generally similar.
Families at the beach with poor water
quality had a slightly lower socioeco-
nomic status (SES) than families at
the beach having good water quality.
The majority of participants in this
study were bathers who generally
immersed their whole body.
The concentrations of the water
variables were found to be signifi-
cantly different (p<0.05) depending
on the time of day and day of weekend
that they were collected. On the
whole, there were no significant dif-
ferences (p>0.05) in the water vari-
ables when measured at five different
water sampling locations at each
beach.
This pilot study did not provide
specific information about the rela-
tionship of health and recreational
water quality. However, a subsequent
study can now be conducted to survey
a large population at beaches with
differing water quality to evaluate this
relationship.
While these efforts explore how
studies might be conducted on fresh
water beaches, a similar research pro-
gram for marine beaches has been
completed.
This Project Summary was develop-
ed by EPA's Health Effects Research
Laboratory, Cincinnati, OH, to an-
nounce key findings of the research
project that is fully documented in a
separate report of the same title (see
Project Report ordering information at
back).
Background Information
Pollution of bathing waters has been
a concern to public health officials for
some time because of the potential for
transmission of infectious diseases.
Reports have suggested that contami-
nated bathing waters may be related to
cases of sleeping sickness, sinus infec-
tions, intestinal upsets, eye inflamma-
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tion, "swimmers' itch," ear infections
and leptospirosis.
Although there is no definitive
evidence that a relationship exists be-
tween water quality and transmission of
mfectiousdisease among bathers, there
is presumptive evidence suggesting
such a relationship. Disease outbreaks
involving leptospirosis, chronic skin
granulomas, shigellosis, primary
amebic menigoencephalitis, and pos-
sibly even hepatitis have been associ-
ated with recreational waters These
are the more serous illnesses that may
be associated with recreational bathing.
Diseases of the eyes, ears, nose and
throat, gastrointestinal tract and skin
are additional illnesses occurring at
relatively higher incidence rates among
bathers than n-onbathers. These ill-
nesses cannot always be associated
with poor quality recreational water.
A few epidemiological studies have
attempted to assess incidence of illness
with bathing in water containing fecal
contamination. These studies reported
some of the following results: an
increase in the incidence of eye, ear,
nose, throat and gastrointestinal tract
infections, higher gastrointestinal ill-
ness levels in river bathers versus
bathers using a swimming pool; no
relationship between illness and water
quality at salt water beaches; sewage-
polluted sea water had a negligible risk
to health; higher incidence of gastro-
intestinal illness between bathers at
more polluted salt water beaches; and
the rate of gastrointestinal symptoms
was higher for swimmers versus non-
swimmers at more contaminated salt
water beaches compared to the uncon-
tarmnated control beaches An
exposure-and-effect relationship be-
tween bacterial levels in recreational
waters has been convincingly demon-
strated only for marine waters
Variations in water quality standards
used for swimming exist because no
physical, chemical, or biological param-
eter has been established to assess
water safety for bathing. Several bacte-
riological surveys of recreational waters
have been conducted with the objective
of determining water quality changes
and safety for use. However, no stand-
ards were established for critical
minimum total coliform, fecal coliform,
fecal streptococci or salmonella
concentration that would be safe for
human contact Although most states
presently have bacteriological stand-
ards and conduct bacteriological
surveys for water quality, there is a
paucity of sound epidemiological or
laboratory evidence that communicable
diseases may be acquired by contact
with contaminated water.
The literature indicates that many dif-
ferent types of bathing-related illnesses
may be acquired through contact with or
ingestion of recreational water There-
fore, it maybe unlikely that one bacterial
indicator will sentinel all health hazards
related to recreational waters.
Organisms such as Staphylococci,
Streptococci, Clostridia and Pseudo-
monads are some of the suggested
indicators of health hazards for recrea-
tional waters. Furthermore, there is no
evidence at present to show that bacte-
riologically clean water may not, on
occasion, contain agents that are
potential health hazards.
Project Design and Methods
Two beaches in the Cleveland, Ohio
metropolitan area on Lake Erie were
chosen for this study. Edgewater Beach
is located in Cleveland on the west side
and is situated near two point sources of
pollution, Westerly Wastewater Treat-
ment Plant and two storm sewer out-
falls. The beach at Headlands State Park
is 40 km east of Cleveland with no
known point sources of pollution.
One hundred families from each
beach were systematically selected to
voluntarily participate in the study over
three weekends in July 1977. Eligibility
for participating was based on Cleve-
land metropolitan area residency and
willingness to be contacted by tele-
phone four times within three weeks to
answer questions about health and
swimming experience.
The initial telephone call following
recruitment collected data characteriz-
ing the swimming experience and
recorded any acute illnesses occurring
in swimming and non-swimming partic-
ipants. The second, third and fourth
follow-up telephone calls, made one,
two and three weeks after the swim-
ming episode (experience), elicited
information on acute illnesses, socio-
economic status and chronic health
problems
A water sampling design was devel-
oped to test water parameters at the two
beaches. The purpose was to determine
if a relationship existed between
physical, chemical and/or biological
components of the bathing water and
the health of the persons bathing in
these waters. Five water samples were
collected in a systematic pattern at each
beach at 0900, 1200 and 1500 hours on
each test day. Each of the 203 water
samples were analyzed for total coli-
forms, fecal coliforms, E. coli fecal
streptococci, Pseudomonas aeruginosa,
total Staphylococci, pH, chloride, BODs,
turbidity, specific conductivity, sus-
pended solids, total solids and tempera-
ture. Meteorological data were also
obtained
Results and Conclusions
This pilot study surveyed a total of 177
families consisting of 634 persons at
both beaches during the three weekend
recruitment periods.
The attrition rates at Edgewater (30%)
and Headlands (15%) beaches during
the study period were low. Attrition was
directly related to family size at Edge-
water but not at Headlands. A promo-
tional letter had no positive effects on
reducing the attrition of families of
either beach. The age characteristics at
both beaches were similar in that the
majority of individuals were less than
15 years of age. Participants differed
from drop-outs in the 0-4 and 5-14 year
old age groups at both beaches. Sex
distribution of participants was the
same at both beaches when compared
with non-participants. A higher per-
centage of families at Headlands Beach
had college or professional school
education than those at Edgewatei
Beach.
Most participants were bathers ai
Edgewater (60%) and Headlands (89%
beaches. A majority of the bathers (63%
reported not bathing at other times
during the study period Also, fewe
people bathed at other times as th<
study progressed. There were meaning
ful differences between bathers ani
non-bathers at either beach with regar
to age, sex, race and educational char
acteristics.
The health information presented i
not an analysis of the effects of wate
quality on health, but demonstrates
method of analysis that could be use
for a larger study. In this pilot stud'
. there were only two illnesses (21
person-days) reported from Edgewate
Beach and 19 (1,470 person-day
reported from Headlands Beach t
individuals who only had total body in
mersion on the day of recruitment
Chronic disease information shou
be included in future analysis of heal
data from beach studies since it mi
alter susceptibility to infections. Tl
results of the study showed that appro
imately 850 families for each bathii
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beach are needed to have an 80%
chance of detecting a difference of 10
per 1,000 between illness rates using a
type 1 error of 0.05.
Although this long follow-up period
was selected to record infectious ill-
nesses with long incubation periods
and determine if the study population
could be followed up successfully via
telephone for three weeks, a two-week
follow-up fs recommended as the most
appropriate for subsequent studies.
Multiple water samples were col-
lected at each beach to determine
differences in these components
between: days the samples were col-
lected, the five collection points at each
beach, the three daily time periods of
collection, and the weekends. All of
these variables were analyzed statisti-
cally using the analysis of the variance
(ANOVA) for two, three and four way
interactions. Water variables were
compared using Schiffe's Multiple
Comparison Test.
Two samples of Lake Erie water were
collected by filtration on July 16and 17,
1977 at Headlands State Park (50 gal-
lons) and Edgewater Beach (63 gallons),
respectively. The filters were processed
at HERL-Cincinnati by organic floccula-
tion and inoculated to tissue culture
cells including: primary African green
monkey kidney, primary human
embryonic kidney, continuous cell line
BGM and continuous line human rhab-
domyosarcoma cells, and agar overlay
using BGM. A virus isolated from the
Edgewater Beach sample using the
overlay procedure was identified as
Coxsackievirus B3 by use of monovalent
Coxsackievirus B3 serum.
The mean concentration for most of
the water measurements for Saturday
and Sunday generally was found to be
significantly different (p< 0.05) for both
beaches. Significant differences
between these water quality variables
were most prevalent between 0900 and
1500 hours at both beaches. Generally,
there were no differences noted be-
tween the five sampling sites at each
beach. When weekends were compared
by day and time of day, many significant
differences (p<0.05) were found for the
microbiological, physical and chemical
variables.
It was necessary to know the time of
day and day an individual was exposed
in order to relate health effects of
recreational water to some water
quality variable. Since major differ-
ences observed between the beaches
were in the microbiological variables
while the physical and chemical vari-
ables were quite similar, only micro-
biological variables need be included in
subsequent studies.
Recommendations
For future beach studies using the
methodology developed in this pilot
study, the following changes are recom-
mended:
1. Attrition would be reduced in
future beach studies by having the
survey workers go directly to the
homes of those families who do
not have home telephones,
2. Families should be asked to con-
tact the survey workers as they
leave the beach to state individu-
ally their bathing experience
relative to amount of body
exposure to the water and length
of exposure.
3. Information should be gathered
about the health status of bathers
and nonbathers on the day of
recruitment.
4. A two-week follow-up period is
minimally required so that long
incubation periods, of various
infectious agents (e.g , viruses)
can be included in the evaluation.
5. Quality of recreational water can
be adequately monitored by samp-
ling the water for microbiological
variables at one central location in
the bathing area instead of the five
locations used in this study, as
long as time of day and day of
weekend are considered.
6. A large scale study should not be
conducted at Edgewater Beach
because less than 250 families
use this beach during the summer
swimming season. Approximately
850 families would have to be
recruited to be able to detect a
significant difference between the
two beaches' illness rate.
The research project on marine
beaches led to the development of a
criteria based on an exposure response
relationship; Health Effects Quality
Criteria for Marine Recreational
Waters, EPA-600/1-80-031 (Septem-
ber 1980). The protocol developed for
the marine project is currently
being used on two fresh water beach
studies.
R. L. Northrop, G. Ft. Brenniman, S. H. Rosenberg, Ft. B. Byington, andC. S. Hesse
are with the University of Illinois at the Medical Center, Chicago, IL 60612.
T. H. Ericksen is the EPA Project Officer (see below).
The complete report, entitled "Recreational Water Quality and Health," (Order
No. 82-103 599; Cost: $12.50, subject to change) will be available only from:
National Technical Information Service
5285 Port Royal Road
Springfield, VA22161
Telephone: 703-487-4650
The EPA Project Officer can be contacted at:
Health Effects Research Laboratory
U.S. Environmental Protection Agency
Cincinnati, OH 45268
if US GOVERNMENT PRINTING OFFICE. 1981 -757-012/7353
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United States
Environmental Protection
Agency
Center for Environmental Research
Information
Cincinnati OH 45268
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