Investigation & Risk Factor Survey of Splash Pads

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ABOUT THE COVER ADVANCEMENT OF THE SCIENCE Water Quality Survey of Splash Pads After a Waterborne Salmonellosis This month’s Outbreak—Tennessee, 2014...... 8 cover article explores the Building the Future of Environmental Public Health Tracking: Proceedings investigation that and Recommendations of an Expert Panel Workshop ...... 14 resulted from an Consumer Perception of the Food and Drug Administration’s Newest Recommended uncommon out- Food Facility Inspection Format: Words Matter ...... 20 break of salmonellosis linked to a Inspector Perceptions of the Food and Drug Administration’s Newest Recommended splash pad. The Food Facility Inspection Format: Training Matters ...... 26 authors also conducted a survey to gauge water quality and patron behaviors at splash pads. Most splash ADVANCEMENT OF THE PRACTICE pads surveyed used a recirculating water sys- Building Capacity: Building Environmental Health Capacity in the Cloud ...... 32 tem, but 21% tested below recommended free residual chlorine levels and 33% contained an Direct From ATSDR: Revisiting Trichloroethylene Contaminated Hazardous indicator of environmental or fecal contamina- Waste Sites After New Science Indicates the Need for a Lower Health Guideline ...... 34 tion. Among the patrons observed, common high-risk behaviors included sitting on the Direct From CDC/EHSB: Tools to Drive Quality Improvement of Vector Control Services...... 38 fountain or spray head and putting mouth to water. The article argues that water venue regu- ADVANCEMENT OF THE PRACTITIONER lations and improved patron education are important to prevent future outbreaks. Career Opportunities ...... 42 For easier and more efficient inspections See page 8. EH Calendar ...... 44 Cover photos: National Institute of Allergy and Infectious visit booth 200 at the NEHA 2017 AEC! Diseases (NIAID) and © iStock.com/pic-a-boo Resource Corner ...... 46 YOUR ASSOCIATION ADVERTISERS INDEX President’s Message: Stepping Back ...... 6 Accela ...... 37 “Make Your Data Work As Hard As You Do!” Custom Data Processing...... 51 NEHA Organizational Members ...... 50 Digital Health Department, Inc...... 5 Eljen Corporation...... 51 Special Listing ...... 52 Evidence for Action ...... 49 HealthSpace USA Inc ...... 64 NEHA 2017 AEC ...... 54 ® Hedgerow Software Ltd...... 47 Heuresis Corporation ...... 13 NEHA News ...... 56 Industrial Test Systems, Inc...... 7 Inspect2GO Environmental Health Software ...... 63 DirecTalk: Musings From the 10th Floor: Distribution > Content > Brand ...... 62 LaMotte ...... 19 MSU Online MS in Food Safety Program ...... 45 NSF International ...... 61 Ozark River/Integrity Distribution ...... 49 E-JOURNAL BONUS ARTICLE Protec Instrument Corporation ...... 41 International Perspectives: Assessment of Noise Level Distributions in Lagos Metropolis Software for Environmental and Consumer Health Agencies Sweeps Software, Inc...... 2 The IAPMO Group ...... 43 and the Potential for Adverse Health Effects ...... E1

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Joshua L. Clayton, MPH, PhD Water Quality Survey Epidemic Intelligence Service, Centers for Disease Control and Prevention of Splash Pads Tennessee Department of Health Judy Manners, MSc After a Waterborne Susan Miller, MS Craig Shepherd, MPH Salmonellosis Outbreak John R. Dunn, DVM, PhD Tennessee Department of Health —Tennessee, 2014 William Schaffner, MD Vanderbilt University School of Medicine Timothy F. Jones, MD Tennessee Department of Health

Methods Waterborne outbreaks of salmonellosis are uncommon. Abstract Outbreak Investigation The Tennessee Department of Health investigated a salmonellosis outbreak of During June 2014, routine disease surveillance 10 cases with the only common risk factor being exposure to a single splash and patient interviews conducted by TDH identifi ed an outbreak of fi ve Salmonella New- pad. Risks included water splashed in the face at the splash pad and no free port infections among patrons of a single splash residual chlorine in the water system. We surveyed water quality and patron pad. Standard outbreak investigation methods behaviors at splash pads statewide. Of the 29 splash pads participating in were used, including case fi nding from local the water quality survey, 24 (83%) used a recirculating water system. Of the healthcare providers, patient interviewing, and laboratory isolation and subtyping by pulsed- 24, 5 (21%) water samples were tested by polymerase chain reaction and fi eld gel electrophoresis (PFGE). A case-con- found to be positive for E. coli, Giardia, norovirus, or Salmonella. Among 95 trol study was performed to identify exposures patrons observed, we identifi ed common high-risk behaviors of sitting on the associated with Salmonella infection among patrons of the implicated splash pad. fountain or spray head and putting mouth to water. Water venue regulations Cases were defi ned as either confi rmed and improved education of patrons are important to aid prevention efforts. (a person who developed diarrhea, defi ned as ≥3 loose stools during 24 hours, within 16 days of visiting the splash pad, and with laboratory confi rmation of Salmonella New- Introduction 2008). During June 2014, the Tennessee port) or probable (a person who developed During 2009, more than 50 million people Department of Health (TDH) investigated diarrhea within 16 days of visiting the splash swam during an estimated 300 million visits a salmonellosis outbreak associated with a pad without laboratory confi rmation). The to recreational waters in the U.S. (U.S. Cen- single splash pad. Splash pads, which are 16-day incubation period for Salmonella sus Bureau, 2011). Included among recre- not regulated in Tennessee, are any fountain was used because the ingestion dose was ational waters are hot tubs, swimming pools, or water spray device intended for or acces- likely low because of the dilution effect of lakes, oceans, and rivers. Among potential sible to recreational use (see photo on page the splash pad water (Heymann, 2004). We risks for recreational swimming is water- 9). A limited number of outbreaks associ- attempted to match three control subjects per borne illness resulting from ingestion of con- ated with splash pads have been reported, case-patient, stratifi ed by age group. Control taminated water. Diarrhea, the most common and a study of water quality was rarely subjects were age matched to case-patients manifestation of waterborne illness, results included (Bancroft, Keifer, & Keene, 2012; and had visited the splash pad in the previ- when a person ingests water contaminated Eisenstein, Bodager, & Ginzl, 2008; Kirian, ous 30 days. Internet directories were used to with enteric pathogens, including Cryptospo- Meregillano, Gennette, & Weintraub, 2008; identify households in the community near ridium, Giardia, Shigella, norovirus, and E. Nett et al., 2010). We investigated the out- the splash pad and telephone calls were made coli O157:H7 (Hlavsa et al., 2011). break of salmonellosis and then conducted to enroll control subjects. TDH staff visited Despite being among the most common a statewide survey of splash pads to learn the splash pad to enroll additional patrons enteric pathogens, nontyphoidal Salmonella more about their water quality and observe as control subjects via in-person contact. is rarely identifi ed as the source of water- patron behaviors that might increase the After the outbreak was identifi ed, a chlorine borne illness (World Health Organization, risk for infection. reading was taken and TDH staff reviewed

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(18–24 hours) at 35 °C. Broth was then tested by drawing a 200 µL sample for the multi- TABLE 1 plex PCR test and, if a Salmonella species was Splash Pad Characteristics present, cultured using standard techniques. Related to Hygiene and Water Quality (N = 29) Patron Observations Splash pad patrons who appeared to be 18 Characteristic # (%) years or younger were observed to examine Recirculated water 24 (83) behaviors that would increase the likelihood of venue contamination or fecal–oral disease Hygienic practices and policies Example of water features at a splash pad. transmission. This patron age group was cho- Signs posted 15 (52) Photo courtesy of Judy Manners. sen for their increased likelihood to participate No food allowed 9 (31) in nonhygienic behaviors. A convenience sam- No drinks allowed 8 (28) Splash Pad Survey ple of children was selected and risk behav- In response to the waterborne Salmonella iors were documented for 15 minutes or until No animals allowed 7 (24) outbreak, we conducted a survey during they left the splash pad area. Risk behaviors Child supervision required 7 (24) August 2014 of all identified splash pads of sitting on a fountain or spray head, putting Exclusion of ill persons 6 (21) in Tennessee to learn about their operat- their mouth to water, putting their fingers in Avoid swallowing water 5 (17) ing characteristics. A comprehensive list of their mouth, putting a hand down their swim Shower before entry 3 (10) splash pads was unavailable, so we identified shorts, and exposing their buttocks to water sites by searching the Internet for terms com- were recorded as present or absent during Recommend swim diaper 5 (17) monly used to name or describe them (e.g., each 1 minute increment of the 15-minute No changing diapers 1 (3) splash pads, interactive fountains, or aquatic observation period (Nett et al., 2010). Written policies 12 (41) playgrounds); reviewing splash pad manufac- Body fluid contamination policy 9 (31) turer web pages for past, current, and future Results Hygienic facilities available projects; and reviewing award announce- ments from the Tennessee Department of Outbreak Investigation Restrooms 17 (59) Environment and Conservation’s parks and All 10 case-patients (5 confirmed and 5 prob- Hand wash sinks 15 (52) recreation grants. Splash pad operators were able) and 27 control subjects were included Drinking water fountains 11 (38) requested to participate in the survey during in a case-control study. All 5 confirmed Fence around facility 10 (35) an unannounced site visit. Participating site case-patients had stool cultures that yielded Food available on or near 10 (34) operators were asked questions addressing Salmonella enterica serotype Newport with premises water recirculation, signage, written policies matching PFGE patterns. The mean age of Showers 5 (17) for hygienic behaviors, and hygienic facilities both case-patients and control subjects was available to patrons. 7 years; 5 (50%) case-patients and 12 (44%) Diaper changing stations 7 (24) During splash pad visits, water samples control subjects were female. No other com- Changing rooms 5 (17) were collected from spray or fountain heads. mon exposure among case-patients was iden- Foot wash stations 4 (14) Free chlorine levels were tested on site by tified after examining shared events, food Water quality using a commercial pool test kit. For micro- histories, and other exposures while at the pH, mean (SD)a 3.7 (3.1) bial testing at TDH’s Division of Laboratory park. All 10 (100%) case-patients had water Services, water samples of 100 mL for coli- splashed in their face while playing in the Free chlorine, mean ppm ( )a 7.5 (0.4) SD form culture and 1 gallon for polymerase splash pad, compared with 19 (90%) of 21 Total coliforms presenta 3 (13) chain reaction (PCR) analysis were collected. control subjects. No free residual chlorine, E. coli presenta 1 (4) Total coliform and E. coli cultures were per- which inactivates potential contaminants, Specific pathogen identifieda,b 5 (21) formed using methods approved by the U.S. was identified in the recirculated water dur- Environmental Protection Agency (Standard ing the TDH staff member’s visit, and the SD = standard deviation; ppm = parts per million. Methods: 9223 B) for drinking water testing. splash pad was closed voluntarily. Review of a N = 24 splash pads with recirculating water. Multiplex PCR (BioFire FilmArray Gastroin- maintenance logs revealed chlorine level test- b1 for Giardia; 2 for enteropathogenic E. coli; 1 for norovirus, and 1 for Shiga toxin-producing E. coli, testinal Panel) analysis was used to test for 22 ing was not routinely logged or performed. enterotoxigenic E. coli, Salmonella, and Plesiomonas enteric pathogens. The gastrointestinal panel After cleaning and hyperchlorination, the shigelloides. is not validated for water samples; therefore, splash pad was reopened. No samples were the state laboratory developed a modified taken before closure and subsequent water the maintenance logs during the initial visit. protocol. Water was passed through a 0.45 samples collected upon reopening did not During a subsequent visit, an environmental µm filter, and the filter was placed into 50 detect Salmonella, total coliforms, or E. coli assessment and water samples were taken. mL of lactose broth and incubated overnight by culture.

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Splash Pad Survey In Tennessee, 59 splash pad locations were FIGURE identiﬁed, and operators were contacted to 1 participate in our survey. Of these 59 splash Observed Rate of Behaviors for Splash Pad Patrons ≤18 Years pads, 29 operators (49%) voluntarily pro- vided water samples for testing. Most of the 12 splash pads, 24 of 29 (83%), used a recirculating water system. Of these, 5 (21%) tested below the 1.0 parts per million (ppm) free residual chlorine recommended by the Model 8 Aquatic Health Code (Centers for Disease Control and Prevention [CDC], 2014) and 2

(8%) tested below the detectable limit. Water Times/Hour

quality testing of the 24 recirculating water of 4 # systems identified 3 (13%) that tested positive for total coliforms, 1 (4%) yielded E. coli by culture, and 5 (21%) tested positive for specific organisms via multiplex PCR (1 for 0 Sit on Fountain Mouth to Water Fingers in Mouth Hands Down Exposed Giardia; 2 for enteropathogenic E. coli; 1 for or Spray Head Pants Buttocks norovirus; and 1 for shiga toxin-producing E. coli, enterotoxigenic E. coli, Salmonella spe- Behaviors cies, and Plesiomonas shigelloides). In total, 8 (33%) of 24 splash pads that recirculated water contained an indicator of environmental or fecal contamination. Discussion of organic material and the most common The 5 nonrecirculating splash pads tested Our investigation documented an unusual waterborne illnesses are infectious at low negative for all organisms, and 2 had free waterborne Salmonella Newport outbreak doses (Gerba, 2000). Water quality testing residual chlorine levels <1.0 ppm. Examin- after patron exposures to insufficiently chlo- for specific pathogens identified contamina- ing hygienic practices and policies at the 29 rinated water at a splash pad that used recir- tion consistent with environmental or fecal splash pads, approximately half had posted culating water. In all, 10 cases of Salmonella sources at multiple venues. Specific patho- hygiene signs (Table 1). Written hygiene pol- were epidemiologically linked to activities gens found in the water included Salmonella, icies were identified at less than half of splash at a single splash pad with no free residual E. coli, Giardia, and norovirus. Although cer- pads, and less than one third reported having chlorine detected in the water. In a survey of tain enteric pathogens might have resulted a written policy for body fluid contamination splash pads, evidence of enteric pathogens— from environmental contamination by birds (e.g., blood, feces, or vomitus). Approxi- including E. coli, Giardia, Salmonella, and or animals, humans are the only known res- mately half of splash pads had hygienic norovirus—was found in splash pads with ervoir of norovirus. facilities, restrooms, or hand wash sinks, and recirculating water systems. The majority of Observations of splash pad patrons 18 approximately one third had a drinking water children observed at splash pads during this years or younger identified that behaviors of fountain available for patrons. Presence of investigation engaged in unsanitary behav- sitting on a spray or fountain head and put- environmental or fecal contamination indi- iors, including sitting on a fountain or spray ting water or their fingers in their mouth cators were not associated with inadequate head and putting water or their fingers in were common. The majority of patrons were water chlorination (p = .14) or the presence their mouths. Recirculation of water at splash young (<5 years old) and therefore less likely of posted hygiene signs (p = .99) or hygienic pads likely allows fecal–oral transmission to be aware of proper hygiene etiquette than facilities (p = .71) at splash pads. of enteric pathogens by prolonging patron older splash pad patrons. These prevalent exposure to contaminated water. but modifiable risk factors can be targeted Patron Observations The majority of splash pads in our survey to reduce the risk for waterborne illness. From 95 patron observations at 17 splash used recirculated water and water quality The Centers for Disease Control and Preven- pads, 20 (21%) were children wearing dia- concerns included no free residual chlorine tion (CDC) recommends patrons minimize pers or swim diapers, and 4 (20%) had a dia- and contamination with enteric pathogens. waterborne illness risk for themselves and per changed in the splash pad area. Patrons Free residual chlorine levels were difficult others by taking frequent restroom breaks, spent an average of 11 minutes per hour sit- to maintain and potentially inadequate to not ingesting the water, and refraining from ting on a fountain spray head, 11 minutes disinfect the water if organic material from water play while ill with diarrhea (Hlavsa et per hour putting their mouth to water, and patrons or the surrounding environment was al., 2011). Signs posted at splash pads can 4 minutes per hour putting their fingers in introduced. Each patron entering the splash help educate patrons and serve as remind- their mouth (Figure 1). pad potentially introduces some amount ers about these prevention steps. Our study

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reported only half of splash pads had any was associated with an interactive fountain in stantial proportion of splash pads surveyed hygiene signs posted, and the facilities to California (Kirian et al., 2008). Similar to our in Tennessee. Vigilance among splash pads support the prevention steps were often not Tennessee outbreak, factors contributing to operators is needed to maintain proper water available at the sites. Only half of splash pads the California outbreak included the recircu- quality. Splash pad patrons should take pre- had restrooms with a toilet and hand sink, lation of water and inadequate disinfection. A cautions to help prevent illness, such as hand and approximately one third had a drinking limited number of drinking water outbreaks washing after using the toilet or before eat- water fountain. were identified with Salmonella as the caus- ing, changing diapers in an area separate A number of splash pads were originally ative agent during the past decade (Ailes et from the splash pad, and avoiding ingestion designed to be decorative rather than recre- al., 2013; Hlavsa et al., 2011). of recreational water. Hygiene signs posted ational sites, helping to explain the limited This study had certain limitations, includ- around these popular water venues can serve attention to water quality by operators and ing that the multiplex PCR, although vali- as a reminder to patrons. Furthermore, toilet, lack of hygiene signs at facilities in our study. dated for stool specimens, was not validated hand washing, and drinking water fountain As prevention of contaminants is not con- for use with water samples and the test sen- facilities located nearby are essential. Public sidered a concern for decorative fountains, sitivity and specificity is not known. The health jurisdictions can consider extending they often have fewer barriers (e.g., fencing) multiplex PCR also does not differentiate existing regulatory oversight for swimming to prevent domestic animals from contacting live from inactivated organisms, an impor- pools to splash pads. the water. Regardless, even gated recreational tant distinction for developing disease. Nev- splash pads are open to contamination by ertheless, five different enteric pathogens Acknowledgements: We thank the Tennessee wild animals and birds. Determining which were identified in splash pad water samples, Department of Health FoodCORE student splash pads are accessible for recreational use and their presence indicates the potential to interviewers for their role in data collection and inspecting them to meet water quality cause disease if effective chlorine disinfec- and the Tennessee Department of Health regulations is a challenge for regulators. tion was not being performed. Our findings Division of Laboratory Services for providing Waterborne outbreaks of salmonellosis are likely underestimated the contamination technical expertise for water quality sampling uncommon (Outbreak Collaborative, 1971; occurring during peak usage in summer and testing. Grant funding for this project Taylor, Sloan, Cooper, Morton, & Hunter, months because the study was performed came from CDC’s National Center for Envi- 2000). During 2009–2010, none of the 33 during August when schools had resumed ronmental Health (RFA-EH-10-001). drinking water outbreaks or 81 recreational and fewer patrons were present. waterborne outbreaks reported to state health Corresponding Author: Joshua L. Clayton, departments was as a result of Salmonella spe- Conclusion Deputy State Epidemiologist, Indiana State cies (CDC, 2013; Hlavsa et al., 2014). During Poor water quality and risky patron behav- Department of Health, 2 North Meridian 2006, a waterborne outbreak of 69 crypto- iors that facilitate fecal–oral transmission Street, 7th Floor, Selig Building, Indianapo- sporidiosis cases and 15 salmonellosis cases of waterborne illness were present at a sub- lis, IN 46204. E-mail: [email protected].

References Ailes, E., Budge, P., Shankar, M., Collier, S., Brinton, W., Cronquist, active water fountain—Florida, 2006. Journal of Environmental A., . . . Brunkard, J.M. (2013). Economic and health impacts asso- Health, 71(3), 18–22. ciated with a Salmonella Typhimurium drinking water outbreak— Gerba, C.P. (2000). Assessment of enteric pathogen shedding by Alamosa, CO, 2008. PLoS One, 8(3), e57439. bathers during recreational activity and its impact on water qual- Bancroft, J.E., Keifer, S.B., & Keene, W.E. (2012). Shigellosis from ity. Quantitative Microbiology, 2(1), 55–68. an interactive fountain: Implications for regulation. Journal of Heymann, D.L. (Ed.). (2004). Control of communicable diseases Environmental Health, 73(4), 16–20. manual, (18th ed.). Washington, DC: American Public Health Centers for Disease Control and Prevention. (2013). Surveillance for Association. waterborne disease outbreaks associated with drinking water and Hlavsa, M.C., Roberts, V.A., Anderson, A.R., Hill, V.R., Kahler, A.M., other nonrecreational water—United States, 2009–2010. Morbid- Orr, M., . . . Centers for Disease Control and Prevention. (2011). ity and Mortality Weekly Report, 62(35), 714–720. Surveillance for waterborne disease outbreaks and other health Centers for Disease Control and Prevention. (2014). The Model events associated with recreational water—United States, 2007– Aquatic Health Code (1st ed.). Atlanta, GA: Author. Retrieved from 2008. Morbidity and Mortality Weekly Report Surveillance Sum- https://www.cdc.gov/mahc/editions/previous.html mary, 60(SS12), 1–32. Eisenstein, L., Bodager, D., & Ginzl, D. (2008). Outbreak of giardia- continued on page 12 sis and cryptosporidiosis associated with a neighborhood inter-

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References continued from page 11 Hlavsa, M.C., Roberts, V.A., Kahler, A.M., Hilborn, E.D., Wade, T.J., Outbreak Collaborative. (1971). A waterborne epidemic of salmo- Backer, L.C., . . . Centers for Disease Control and Prevention. nellosis in Riverside, California, 1965. Epidemiologic aspects. (2014). Recreational water-associated disease outbreaks—United American Journal of Epidemiology, 93(1), 33–48. States, 2009–2010. Morbidity and Mortality Weekly Report, 63(1), Taylor, R., Sloan, D., Cooper, T., Morton, B., & Hunter, I. (2000). A 6–10. waterborne outbreak of Salmonella Saintpaul. Communicable Dis- Kirian, M.L., Meregillano, G., Gennette, D., & Weintraub, J.M. eases Intelligence, 24(11), 336–340. (2008). Multi-jurisdictional investigation of interactive fountain- U.S. Census Bureau. (2011). Statistical abstract of the United States: associated cryptosporidiosis and salmonellosis outbreaks. Epide- 2012 (131st ed.). Washington, DC: Author. miology and Infection, 136(11), 1547–1551. World Health Organization. (2008). Guidelines for drinking-water Nett, R.J., Toblin, R., Sheehan, A., Huang, W.T., Baughman, A., & quality—Volume 1: Recommendations (3rd ed.). Geneva, Switzer- Carter, K. (2010). Nonhygienic behavior, knowledge, and atti- land: Author. tudes among interactive splash park visitors. Journal of Environ- mental Health, 73(4), 8–14.

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