Waterborne Illness

Aka: Waterborne Illness, Recreational Waterborne Illness, Water-borne Diarrheal Infection, Water-borne Transmission, Swimming Related Illness

1. See Also
   1. Foodborne Illness
   2. Infectious Diarrhea Causes
   3. Diarrhea
   4. Traveler's Diarrhea
   5. Gastrointestinal Disease in Returning Traveler
   6. Vector Borne Disease
   7. Pet-Borne Infection
   8. Fever in the Returning Traveler
   9. Marine Injury
   10. Skin Infection
2. Risk Factors
   1. Travel to endemic areas of Waterborne Illness
   2. Hiking in wilderness areas (especially drinking from mountain streams)
   3. Public pools
   4. Hot Tubs
   5. Ingested water
      1. Untreated water
      2. Unpasteurized dairy products
3. Precautions
   1. Chlorination does not completely eliminate the risk of waterborne infection
      1. Cryptosporidium can survive 10 days in water at CDC recommended levels of chlorination and pH
      2. Giardia oocysts can survive in chlorinated swimming pools and hot tubs
      3. Adenovirus (strains 4 and 7) is commonly associated with swimming pool related Diarrheal outbreaks
4. Causes: Waterborne Diarrheal infection
   1. Bacteria
      1. Escherichia coli (rapid onset 12-72 hours)
      2. Nontyphoidal Salmonella (rapid onset 12-36 hours)
      3. Shigella (Intermediate onset 1-3 days)
      4. Yersinia enterocolitica (slow onset 3-7 days)
      5. Campylobacter jejuni (Intermediate onset 3-5 days)
      6. Leptospira (onset delayed 4-19 days)
      7. Brucellosis
      8. Vibrio Cholera
      9. Aeromonas
   2. Virus
      1. Hepatitis A (delayed onset 15 to 50 days)
      2. Norovirus (rapid onset 12-48 hours)
      3. Adenovirus
      4. Rotavirus
   3. Protozoa
      1. Giardia (Onset delayed 5-25 days)
         1. Giardia lamblia
         2. Giardia intestinalis
      2. Cryptosporidium parvum (Onset delayed 2-10 days)
      3. Entamoeba histolytica (Amebiasis)
   4. Other
      1. Algae bloom (cytotoxin mediated)
5. Causes: Swimming Related Illness
   1. Gastrointestinal Illness
      1. See above
      2. Giardia lamblia or intestinalis (Onset delayed 5-25 days, common)
      3. Cryptosporidium parvum (Onset delayed 2-10 days, common)
      4. Leptospira (onset delayed 4-19 days)
      5. Escherichia coli (rapid onset 12-72 hours)
      6. Hepatitis A (delayed onset 15 to 50 days)
      7. Norovirus (rapid onset 12-48 hours)
      8. Adenovirus
      9. Rotavirus
      10. Algae bloom (cytotoxin mediated)
   2. Respiratory Illness
      1. Legionella
         1. Legionella pneumonia
         2. Pontiac Fever (Influenza-like illness)
      2. Chemical Pneumonitis (Chlorine gas)
      3. Acute Otitis Externa (Swimmer's Itch)
      4. Sinusitis
         1. Sinus symptoms in 40% of swimmers (but resolves spontaneously in nearly all)
         2. Serious infections are rare (e.g. Primary Amebic Meningoencephalitis, Vibrio alginolyticus)
   3. Neurologic Illness
      1. Primary Amebic Meningoencephalitis (rare, Naegleria fowleri Sinusitis complication)
   4. Skin or soft tissue infection
      1. Swimmer's Itch (Cercarial Dermatitis, schistosome mediated)
      2. Hot Tub Folliculitis (Pseudomonas aeruginosa)
      3. Cellulitis
         1. Typical Bacterial Cellulitis (Staphylococcus, Streptococcus)
         2. Aeromonas Hydrophila
         3. Pseudomonas aeruginosa
         4. Mycobacterium marinum (Nodular Lymphangitis)
         5. Vibrio vulnificus (risk of Necrotizing Fasciitis)
6. Prevention
   1. See Water Disinfection
   2. See Prevention of Waterborne Illness
7. References
   1. Barr (2014) Am Fam Physician 89(3): 180-9 [PubMed]
   2. Perkins (2017) Am Fam Physician 95(9):554-60 [PubMed]
   3. Scallen (2011) Emerg Infect Dis 17(1): 7-15 [PubMed]