How often do you see dry swimmers entering your pool? Until two years ago, that was a regular occurrence at South Davis Recreation Center in Bountiful,Utah. A shower-first policy was in effect, but most swimmers simply ignored the rule, recalls Scott McDonald, aquatics and fitness director.

But those attitudes changed for good after summer 2007, when Utah experienced one of the largest cryptosporidium outbreaks ever linked to recreational water. Today, McDonald regularly overhears patrons reminding each other to shower, and few complain if they are asked to hit the showers before swimming.

He’s made some policy changes as well. A guard often is posted at the locker rooms to remind patrons of the rules, and each swim season McDonald makes a point of informing coaches about how important it is for their teams to abide by the shower policy.

Swimmers and facility operators in Utah learned the hard way what health officials have been saying for some time: When it comes to crypto, many of the old protocols aren’t enough. In other words, simply relying on chlorine disinfection to make up for lax hygiene won’t stop the parasite. Nor is it acceptable to hope that new crypto-killing technological “silver bullets” will solve the problem.

Experts say that effective crypto prevention requires a new strategy. “Think of healthy swimming as a three-legged-stool, with one leg being public health agencies, one being aquatics operators, and the last being the pool-visiting public,” says Michele Hlavsa, an epidemiologist at the Centers for Disease Control and Prevention in Atlanta. “If any one of the three legs fail, then healthy swimming won’t hold up.”

Surprisingly, it appears some operators are not yet carrying their share of the load. Experts say many aquatics professionals still worry that talking about squeamish subjects such as feces (the main way crypto enters recreational water) will scare the public away from the water.

Anecdotal evidence suggests otherwise, and health officials warn that those fears can be just as dangerous as failing to shower before swimming. What it comes down to is this: If operators and patrons do their part, in conjunction with public health officials, it’s possible to reduce the risk of crypto without risking anyone’s reputation. The alternative may be facing those patrons after an outbreak has already occurred, when they — and their attorneys — are in a far less forgiving mood.

Combining efforts

How well does patron education combined with operators redoubling their efforts and employing the latest technology against crypto work? Just ask Donna Russell.

In 2007, Utah documented nearly 2,000 crypto cases. In 2008, the state recorded only 30. “I think it’s amazing that we didn’t have any outbreaks last year,” says Russell, aquatics supervisor at the Clearfield Aquatics Center in Clearfield, Utah. “Usually it’s more than a one-year cycle.”

While it’s too early to call these decreases a trend, operators such as Russell credit 2008’s success to a combination of operator response and public awareness.

Across the state, health agencies such as the Salt Lake Valley Health Department have worked with medical care providers and aquatics professionals to develop comprehensive campaigns to contain the outbreak and prevent a repeat performance. Here’s what that agency did:

  • Crypto testing was required for anyone seeking gastrointestinal issue-related medical care.
  • A public education campaign was launched, including televised public service announcements and informational materials for groups such as the YMCA.
  • Signs informing patrons of crypto dangers and proper hygiene were posted at aquatics venues.
  • Press conferences were organized to further spread the word about the need for patrons to help prevent crypto, along with healthy swimming behaviors.
  • Strategies were formulated to improve communication between health officials, medical professionals and facility operators.
  • UV systems were installed in 35 Salt Lake County public pools.

Though there’s no way to scientifically gauge the effectiveness of these measures, Linda Bogdanow, epidemiology supervisor at the Salt Lake Valley Health Department, reports that in the four weeks following implementation of control measures, the number of confirmed crypto cases dropped an average of 55 percent each week.

“It ended on a positive,” Russell says of the outbreak. “As the patrons talked to us and watched the news, they understood [their responsibility]. I don’t think we’ve had any long-lasting effects; our programs are as busy as they’ve always been.”

Educating patrons

As the Utah example demonstrates, fighting crypto requires a collaborative strategy. But that doesn’t explain two of the main reasons such a strategy is so necessary in today’s facilities. First, larger and more elaborate aquatics centers can accommodate much bigger bather loads. Second, the pool is no longer just about swimming. Patrons of all ages, sizes and abilities are jumping in for fitness, therapy and, most of all, recreation.

For that reason, the goal is to keep the parasite from ever getting in the water in the first place.

“Prevention is still the most important thing we can do,” says Tom Lachocki, Ph.D., CEO of the National Swimming Pool Foundation in Colorado Springs, Colo.

Not everyone has gotten the message, though. “There’s been good progress, but there’s still room to improve consumer awareness on how they can help to keep themselves healthy,” Lachocki adds.

Indeed, a December 2008 Aquatics International survey of approximately 400 readers found about 15 percent of respondents have not implemented information campaigns to specifically prevent crypto. And in interviewing crypto cases from a 2008 outbreak in New Mexico, CDC researchers found roughly 30 percent of those infected went swimming while ill.

Julie Marsden reports similar findings. As director of the Division of Communicable Disease Control and Prevention for the Montgomery County (Pa.) Health Department, she investigated a 2007 outbreak that included 51 crypto cases stemming from a local day camp. Education probably could have prevented some of them, she says. “They were not aware of the two-week recommendation until we brought it to their attention via the investigation,” Marsden recalls.

So what healthy swimming behaviors should you expect of patrons?

Joan Shields, a former CDC Foundation Fellow now with the FDA, sayscrypto prevention simply comes down to good hygiene. The CDC suggests the following practices for everyone who enters a public pool:

  • Refrain from swimming when you have diarrhea. Stay out of the water for at least two weeks after symptoms disappear.
  • Avoid getting pool water in your mouth and, if you do, don’t swallow it.
  • Wash your hands after using the toilet or changing diapers.
  • Shower before swimming and after using the restroom.
  • Don’t change diapers at poolside.
  • Make sure children take regular bathroom breaks.

The bottom line is, “pool patrons need to realize that they’re part of keeping the water clean,” says Linda Golodner, president emeritus of the National Consumers League. To spread this message, Golodner helped develop the Healthy Pools campaign, a joint effort of the NCL, CDC,Water Quality and Health Council,American Chemistry Council and the Association of Pool & Spa Professionals. That public information campaign, along with additional efforts by CDC and other agencies, includes free marketing resources such as fact sheets, signage and fliers. Available online, these useful tools are ideal for operators who don’t have the time or budgets to create their own.

Golodner adds that it’s important to place materials where patrons are sure to notice them. She also suggests creating education specifically for children. You might even make it part of a learn-to-swim program. For this impressionable demographic, direct communication may be particularly important. The CDC recommends developing a short safety and RWI orientation for kids, and other larger groups, before allowing them in the pool.

These ideas sound simple, Lachocki says, but “[some] operators still believe that if they educate patrons, they’ll lose customers and their business will go under.”

That attitude can be disastrous. Large outbreaks such as the one in Utah have put crypto on the mainstream media map. And in today’s Google-centric world, patrons can easily access crypto information on their own. Once they do, they’re likely to question why their pool operator didn’t warn them, especially if they get sick. In that case, the inquiry may come directly from a lawyer.

On the other hand, if you’re proactive, there’s no reason to see educated patrons as a threat, Hlavsa says. “Look at them as allies who can help get the message out,” she suggests. “That’s a much more powerful tool to help get someone to reconsider their line of thinking.”

Changing operations

Unfortunately, as Hlavsa also notes, “Not every swimmer will self-police.” That’s where operators come in. Leading by example, you and your team can help reinforce the healthy swimming messages you’ve preached.

That means setting policies to ensure safe behavior and publicly enforcing them. Provide clean, convenient restrooms and ask for parents’ help in keeping the diaper-changing area clean. Many operators also report success with scheduled bathroom breaks; they clear the pool hourly and remind patrons to use the restrooms.

It may take time for some patrons to come around, but if you explain that the reason behind the rules is to protect their health, most operators discover the public will happily comply.

Even if every patron abides by rules, fecal accidents happen. With increased programming and recreational opportunities for little ones, seniors and special populations, the risk is greater than ever. So operators need to be prepared with a defined fecal response plan, experts say.

In some places, codes may require documented fecal response protocols. But 20 percent of operators lack comprehensive and up-to-date plans, according to the Aquatics International survey. If you need more information to update or create a plan for your pool, a detailed set of fecal response guidelines is available online from the CDC.

Fecal accidents aren’t pleasant, and neither is the fact that everyone carries trace amounts of fecal matter. Sooner or later, crypto will find a way into your pool.

Fortunately, a number of proven operational strategies can be combined with chlorine to help mitigate the threat of crypto once it’s in the water. These supplemental technologies include UV sanitization, which destroys crypto in water that passes by an ultraviolet light source; ozone systems, which inject ozone (a gas composed of three oxygen molecules) on the pool filter that works in tandem with a chemical coagulant to better facilitate the decomposition of organic materials; and chemical clarifiers.

The addition of a chemical clarifier also can significantly increase the effectiveness of chlorine, according to researcher James Amburgey, University of North Carolina at Charlotte. Other research has shown that because they remove smaller particles, DE filters are more effective at eliminating crypto oocysts from pool water than traditional sand filters.

All of these developments are promising, and approximately 20 percent of the survey respondents claim to have either a UV or ozone system in place. However, there are drawbacks to the technology. Everything comes with a hefty price tag — as much as $50,000 for a large commercial pool — and nothing is 100 percent effective.

ooking ahead

Science and technology may someday provide a magic bullet that completely destroys crypto, but until then, the only surefire way to remove it from your pool is maintain a concentrated level of chlorine for a specific period of time.

Approximately 45 percent of the survey respondents say they regularly hyperchlorinate. Yet as Hlavsa points out, pools must be closed, and the process requires long hours and large amounts of chemicals. And, of course, as soon as the pool is reopened and one swimmer jumps in carrying crypto, the water becomes infected again.

According to Lachocki, researchers are seeking better solutions, one of which may be the chemical compound chlorine dioxide. It’s been shown to effectively destroy crypto, but there’s not yet a safe, practical way to use it  in a real-world setting.

Ultimately, Hlavsa says the ideal disinfectant would not be turnover dependent, meaning it would destroy crypto as quickly as standard chlorination does other pathogens.

Time will tell whether such a product is developed, but until then evidence suggests that if operators educate patrons and use what’s available, crypto doesn’t have to dampen the aquatic fun.

Less than 5 percent of survey respondents report ever having been notified by health officials that a crypto case had been linked to their facility, and it appears the number of crypto outbreaks decreased last year. CDC researchers are still analyzing the data, but Hlavsa says so far the agency has only received 15 provisional reports of RWI outbreaks for 2008 to date, about half of which were caused by crypto. A total of 26 outbreaks occurred in 2007.

Despite that good news, health officials know another outbreak is looming — especially for operators who aren’t bringing patrons into the fight.

“Being honest with people and asking for their help to reduce the risk of crypto is the only mature way to grow business over the long term,” Lachocki says. “We can’t hide from problems like crypto. The best way to deal is to hit them head on.”