Experts highlight common waterborne illnesses, preventive tips for summer

Experts emphasize prevalent waterborne illnesses and offer preventive advice for the summer season.

This article originally appeared on our sister site, Contemporary Pediatrics.

In this Q+A interview, Tina Tan, MD, FAAP, FIDSA, FPIDS, and Shreya Doshi, MBBS, FAAP, highlight common waterborne illnesses as summer ramps up and children, adolescents, and teenagers are in the water more frequently compared to other times throughout the year. Tan is the editor in chief of Contemporary Pediatrics, professor of pediatrics at the Feinberg School of Medicine at Northwestern University, and is a pediatric infectious diseases attending at Ann & Robert H. Lurie Children’s Hospital in Chicago, Illinois. Doshi is a board-certified pediatrician and infectious diseases fellow at Children’s National Hospital in Washington DC.

Contemporary Pediatrics:

What reminders do you have for pediatric providers as they see children in the summertime related to waterborne illnesses? What should they be looking for?

Tina Tan, MD, FAAP, FIDSA, FPIDS:

I think they have to ask whether or not kids have been in the water, and it depends on the type of water that they've been in. Recreational waterborne illnesses are caused by either microorganisms or chemicals that are in the water, and they can be spread by swallowing contaminated water, which is actually the most common way that kids get sick, breathing in contaminated water that has been put into a mist or steam, or having contact with contaminated water. This can actually lead to a number of different manifestations. You can have GI manifestations, which are the most common, so you can get diarrhea, you can get respiratory problems, you can get neurologic problems, ear infections, eye infections, and skin infections. There are a number of different ways that a recreational waterborne illness can present, and the pediatrician needs to ask whether or not the person has been in a swimming pool versus in a lake, a pond, the ocean, because you can get different things depending on what you've been in.

Shreya Doshi, MBBS, FAAP:

Between 2000 and 2014, the Centers for Disease Control and Prevention (CDC) reported more than 630 outbreaks of recreational water illnesses, and this resulted in about 30,000 cases of illnesses and 10 deaths. So, it's really important that we talk about prevention here, not just treatment.1

Contemporary Pediatrics:

What are common skin infections associated with water?

Tan:

The most common you always hear about is hot tub rash, which is usually caused by Pseudomonas. You don't want people sitting in a hot tub too long and then not washing themselves off, because the Pseudomonas can get on your skin and if there are any little breaks or scratches in the skin, infections can occur. The other thing you always hear about is swimmer’s itch. So, people go into water, they go swimming, they come out, and they break out in a dermatitis, and this is usually in natural bodies of water because it's an allergic reaction to parasites that birds, basically, or other mammals, dump into the water. The parasite usually lives in these bodies of water, and the bird might eat it, the other mammal might eat it, and they basically are dumping this parasite into the water, and that's what causes this allergic reaction.

Contemporary Pediatrics:

What are other examples of infections providers should be aware of associated with the water?

Doshi:

The most common that I can think of is the Cryptosporidium species, which causes majority of these infections. Second to that is Legionella Pseudomonas, which causes the hot tub rash, acute otitis externa, also known as swimmer's ear. Then some more common viral illnesses, like norovirus, sapovirus, particularly common during the summer months, as well as pathogenic E coli, which causes diarrhea, Shigella infections and very rarely, we do see an infection called naegleria fowleri, which can cause primary amoebic encephalitis or meningoencephalitis, and it's a very fatal infection.

Cryptosporidium transmission can be caused sometimes because it has a very low infectious dose and causes immediate infectiousness upon excretion, and high pathogen excretion volume, in addition to poor swimmer hygiene. If you have patients that are swimming when they have diarrhea, that can cause easy transmission as well as swimmer behavior. What is the swimmer doing while swimming? Are they ingesting large volumes of water during swimming? If so, then it can easily cause Cryptosporidium infection. One or more swimmers who are ill with diarrhea can contaminate large volumes of water and expose large numbers of swimmers to Cryptosporidium species and other pathogens, particularly if the pool is not disinfected adequately. So especially if you have toddlers with diarrhea, then keep them out of the pool. Not only should you avoid when you have diarrhea, but for Cryptosporidium, avoid it up to 2 weeks after your symptoms have stopped.

Tan:

The acute respiratory illnesses are going to present like any type of respiratory illnesses. Kids are going have a cough, they might have a little bit of a runny nose, and they might complain that it kind of hurts when they breathe. That's more common with the water parks that have the vapor or the mist-type of fixture, because that just aerosolizes the organism.

Contemporary Pediatrics:

What can providers tell families regarding public access to water such as resorts or water parks, and what advice can you offer for treatment after infection?

Tan:

When you go to the water park, even though there's chlorine in the water, you don't want too many people pooping and peeing in the water, because you can pick up infections from that also. If you're out in nature, you really can't control a lot of that, other than really trying to rinse yourself off well after you come out of the water. The other thing to mention in the summer, and it's more common in the south where you have stagnant fresh water, either ponds or lakes, children can get amoebic meningitis. What happens is people dive into these stagnant bodies of water, and the way that the amoeba gets into your brain is that it goes up through your nose, and when people dive, they push it up into the nasal cavity, which can go up to the brain. Unfortunately, most of the time, that is a fatal infection.

There is not just 1 antibiotic that you can use to treat these infections, so you really have to identify what's causing this. If it's a parasite, antibiotics don't work. Norovirus is another thing that can be picked up. If children are in a freshwater area or even at a pool where someone has norovirus, you can pick that up, and that's not going to be treatable other than with time. You just basically have to try and identify what's causing the infection.

Reference:

1. Prevention of illnesses associated with recreational water use. American Academy of Pediatrics Red Book. Published online January 1, 2021. doi:10.1542/9781610025782-S2_010.