ΝΕΑ ΔΕΔΟΜΕΝΑ ΣΤΗΝ ΥΓΙΕΙΝΗ ΤΩΝ ΚΟΛΥΜΒΗΤΗΡΙΩΝ Καθ Αθηνά Μαυρίδου Τμήμα Ιατρικών Εργαστηρίων ΤΕΙ Αθήνας

David Hockney 1966

David Hockney Swimming Pool (1980)

ΠΡΟΒΛΗΜΑΤΑ Τεκμηριώνεται υδατογενής μετάδοση λοιμώξεων μέσω κολύμβησης. Τεχνητά περιβάλλοντα κολύμβησης υπεύθυνα για το 90% των περιστατικών. Επιπτώσεις στην δημόσια υγεία Επιπτώσεις στην τουριστική βιομηχανία Στην παρούσα παρουσίαση επισκόπηση της έρευνας highlight ασυνήθιστων περιστατικών/ επιδημιών ειδικές περιπτώσεις /φυσικές δεξαμενές Το μέλλον της έρευνας

Τι προκαλούν Ωτίτιδες, δερματοπάθειες Επιπεφυκίτιδες κερατίτιδες Λοιμώξεις του άνω αναπνευστικού Γαστρεντερίτιδες Ηπατίτιδα A και άλλες ιογενείς λοιμώξεις Πνευμονία Μηνιγγίτιδα

Από που προέρχονται Από την παροχή του νερού Από τον περιβάλλοντα χώρο Μέσω του δέρματος των κολυμβητών Από το άνω αναπνευστικό των κολυμβητών Από εμετούς Από κόπρανα ανθρώπων, ζώων και πτηνών Από τα αποδητήρια και αποχωρητήρια Από ρύπους μέσω της ατμόσφαιρας και μεταφορά μέ τον αέρα

Πύλες εισόδου Ασυνέχεια δέρματος Κατάποση Μύτη Εξω γενητικό σύστημα Τραύματα αναπνοή

ΥΛΙΚΟ ΕΠΙΣΚΟΠΗΣΗΣ Proceedings of 5 European Swimming Pool and Spa Conferences. Review της δημοσιευμένης βιβλιογραφίας. Στοιχεία διεθνών Οργανισμών. Μελέτη στην Μεσόγειο (Mavridou, WHO)

Eρώτημα Μήπως οι ερευνητές προσανατολίζονται σε συγκεκριμένα παθογόνα?

1. Budapest Αssessments/surveys 9 papers Legionella spp2 papers Amoebae1 paper 2. Munich Assessments/surveys/statistics 6 papers Cryptosporidium/(Giardia) 5 papers (40%) Staphylococcus spp 1 paper Legionella spp1 paper Special issues 2 papers The five European Swimming Pool and Spa Conferences

3. London Assessments/surveys/statistics 2 papers Crypto/(Giardia)4 papers(44.5%) NTMs2 papers Fungi/occupational1 paper 4. Porto Assessments/surveys/statistics 2 papers Cryptosporidium spp 3 papers (50%) Potential pathogens1 paper

The five European Swimming Pool and Spa Conferences 5. Rome Assessments/surveys/statistics 4 papers Cryptosporidium spp 1 paper (7 %) Legionella spp 5 papers P. aeruginosa2 papers Amoebae 1 paper Adenoviruses1 paper

Crypto

ΕΠΙΣΚΟΠΗΣΗ ΒΙΒΛΙΟΓΡΑΦΙΑΣ

Risk factors for Shiga toxin-producing Escherichia coli infections in preadolescent schoolchildren in Buenos Aires, Argentina Epidemiological survey, 883 students, years old Exposure to risk factors (eating hamburgers, swimming, potable water, personal hygiene) “Only 30.2% of students washed their hands after going to the toilet and only 43.5% reported hand-washing before eating” (Bentancor et al, 2012)

THE INTERNATIONAL LITERATURE 181 διεθνείς μελέτες 43 (24%) στη Μεσόγειο WHO MED- Project : – Διερεύνηση νομοθεσιών στιςΜεσογειακές χώρες Εργαλεία: – Ερωτηματολόγια – Βιβλιογραφία – CDC, ECDC Eurosurveillance

PATHOGEN NO. OF STUDIES (International /Med) % (International/Med) ASSESSMENTS ,328 E.COLI 0157: H PSEUDOMONAS/ STAPHYLOCOCCUS 9/25/ LEGIONELLA NTMs PARASITES GENERAL/VARIOUS CRYPTO/ GIARDIA 292/ AMOEBAE ACANTHAMOEBA/NAEGLERIA 101/ SCHISTOSOMA FUNGI ADENOVIRUSES/ENTEROVIRUSES/NOROVIRUSES 11/1/31/1/ WEST NILE VIRUSES PAPILLOMA/ECHOVIRUSES 1/51/23.37 VECTORS TOTAL18143(23%)

INTERNATIONAL/MEDITERRANEAN PATHOGENSNO. OF STUDIES Intern’l Med % Intern’l % Med ΑSSESSMENT /BACTERIA PARASITES VIRUSES FUNGI VECTORS 21 TOTAL18143

INTERNATIONAL AUTHORITIES/REVIEWS ORGANISATIONCOUNTRYOUTBREAKSCASESREFERENCE CDC WBDOSS USA, AGI-total 229 AGI -pools 166 (72,5%) bacteria 23 (13.9%) viruses 10 (3.1%) Crypto 123 (74.1%) Barna & Kadar, 2012 CDCUSA TOTAL 116 Crypto 58/105 total confirmed HAVSLA 2011 CDCUSA E.coli O:157:H7 total recreational 31 pools 10 Rangel, 2005 CDC WBDOSS USA Noroviruses Total/noroviruses 2/2 56CDC, 2011 CDC WBDOSS USA Legionella 24Barna & Kadar, 2012

National- UK ORGANISATIONCOUNTRYOUTBREAKSCASESREFERENCE England/ Wales AGI-Total 89 AGI-pools 35 (39%) Crypto 32 Giardia/Crypto 2 762Smith et al, 2006 UK Crypto 45Nichols, 2nd Conf

EUROSURVEILLANCE 1. Eurosurveillance, Vol. 14, Issue 8, 26 February 2009 A swimming pool-related outbreak of pharyngo-conjunctival fever in children due to adenovirus type 4, Gipuzkoa, Spain, 2008 J Artieda () 1, L Piñeiro 2, M C González 3, M J Muñoz 4, M Basterrechea 1, A Iturzaeta 2, G Cilla 2 2. Eurosurveillance, Vol. 13, Issue 45, 06 November 2008 Surveillance and outbreak reports A swimming pool-associated outbreak of cryptosporidiosis in Staffordshire, England, October to December 2007 N Coetzee () 1, O Edeghere 1, J M Orendi 2, R Chalmers 3, L Morgan 1

«Ασυνήθιστα περιστατικά» Schistosoma Amoebae/Acanthamoebae/Naegleria Fungi/Dermatophytes Helminths Echoviruses/Enteroviruses Vectors/West Nile Virus

Τουρισμός- κλιματική αλλαγή Τάση προς εξωτικούς προορισμούς Τα τουριστικά πακέτα περιλαμβάνουν Spa Υδροθεραπεία «φυσικές» πισίνες Στα ξενοδοχεία η πισίνα θεωρείται απαραίτητη

Bacteria “Faecally derived bacterial pathogens, once dominating the waterborne outbreak reports, seem to represent an altogether low risk. Some of the ill-famed ones, like Salmonella species, including S. typhi, S. paratyphi seem not at all to be implicated in recreational water-borne outbreaks.” Most important E. coli O157:[H7] Barna & Kadar 2012

Schistosoma CountrySourcePathogenCasesReference Belo Horizonte, BrazilHoliday Resort, pool through snails in water S. mansoni.17Enk MJEnk MJ, 2003 Upper Benue valley, Cameroon Water –contact points harboring snails Parameters + assess: Age, information, ethnic group, sex Duration of exposure (swimming 2 nd longer) S. mansoni S. haematobium StudyNdassa ANdassa A, 2007 EgyptA new suggestion. Artificial plastic swimming pools as prophylactic measures against infection with schistosomiasis in developing countries. Abd-Rabbo HAbd-Rabbo H., 1968

Schistosoma CountrySourcePathogenCasesReference Dogon, MALI Dutch travellers Freshwater pools S. intercalatum S. haematobium 28Visser LGVisser LG, 1995 Upper Rhine GERMANY Excavation pool excessive nutrient input Trichobilharzia szidati Swimmer's itch outbreaks Allgöwer RAllgöwer R, 1991 Ecological study

Geographic distribution of schistosomiasis (CDC, 2012)

Amoebae COUNTRYSOURCEPATHOGENCASESREFERENCE SWITZERLAND4 hot springs Filtration unit Echinamoeba exundans 1/4 positive pools Gianinazzi CGianinazzi C, 2010 W Pomerania, POLAND 86 sites/299 samples Pools Lakes Rivers Ponds Thermophilic amoebae Acanthamoeba Naegleria, Balamuthia mandrillaris Sappinia diploidea 223 positive samples Górnik KGórnik K, 2005 Paper in Polish Mexico City, MEXICO Swimming pools, physiotherapy tubs Acanthamoeba Vahlkampfia, Hartmannella, Naegleria 29 strains, 8 genera Rivera FRivera F, provinces THAILAND Acanthamoeba 13.2% Naegleria 35.3% 26/68 positiveLekkla ALekkla A, 2005

Acanthamoebae the Trojan Horse of the Microbial World 90% of healthy humans can carry Acanthamoeba antibodies. Seropositivity occurred in the following order: » Caucasians » Hispanics » African Americans (Chappell et al, 2001).

Acanthamoebae - Trojan Horse of the Microbial World CountrySourcePathogenCasesReference GERMANYStudy of 100 poolsLimax amoebae Genus Acanthamoebae Invasion of CNS certified causing Meningo- encephalitis 34 positive water samples Kuhlencord AKuhlencord A, 1989 Lublin, POLAND Indoor pools Outdoor pools Acanthamoeba spp All samples positive Toczołowski JToczołowski J, 2000 study SWITZERLANDHeated swimming polls Acanthamoeba lenticulata Causing GAE Potential pathogen Gianinazzi CGianinazzi C, 2009 Ahvaz, IRANPools, rivers, canals, soil Acanthamoeba spp. T2, T4, T5 71% of water samples Rahdar MRahdar M, 2012

Acanthamoebae CountrySourcePathogenCasesReference Brasilia, BRAZILSoil, swimming pools, water Acanthamoeba T4, T5 (in pools) Potential Acanthamoeba keratitis Alves Dde SAlves Dde S, 2012 SLOVAKIASwimming in pools with contact lenses 3 cases Acanthamoeba sp. Group III A. ludgunensis A. keratitis Ondriska FOndriska F, 2004 Petaling Jaya Kuala Lumpur MALAYSIA 14 pools 4 sites / pool Acanthamoeba spp N. fowleri All pools/samples 8 pools/3 sites Init IInit I, 2010 study Szczecin, POLAND 10 public indoor pools 3 public open- air pools 16 strains of thermophilic Acanthamoeba spp AD 16, AD 148, AD 166, AM 17, and AM 148 ALL POOLS POSITIVE Górnik KGórnik K, 2004

Naegleria CountrySourcePathogenCasesReference SLOVAKIA1 pool repeated cases/out- breaks ( ) N. fowleri??Kadlec VKadlec V, 1980

How long do dermatophytes survive in the water of indoor pools? Trichophyton rubrum, Trichophyton mentagrophytes and Candida albicans were shown to survive at least 123 days in chlorinated swimming-pool water of degrees, at least 18 days in ozonized water at degrees, and at least 25 days in pipe water at room temperature of degrees. Concentrations of chlorine and ozone normally used to inhibit bacterial contamination did not devitalize the fungi used in the experiment. Fischer E: Dermatologica Oct;165(4):352-4 Fischer E: Dermatologica. Dermatophytes

Fungi-Dermatophytes CountrySourcePathogenCasesReference South East NIGERIA Swimming pools Penicillium sp, Rhizopus sp, A.Versicolor Fusarium s, T. mentagrophytes, Mucor sp C albicans A. niger Absidia sp – 10 7 cfus/ml Itah AYItah AY, 2004 assessment Tsukuba JAPAN Pools Athletes Non- athletes 85% Trichophyton mentagrophytes 63.6% of the swimming class students Athletes more than non- athletes Kamihama TKamihama T, 1997 A study

Fungi- Dermatophytes CountrySourcePathogenCasesReference Reykjavik, ICELAND Dressing rooms male/female T. ubrum (88.6 %) T. mentagrophytes E. floccosum + samples 7.5% women 81% men Hilmarsdottir IHilmarsdottir I, 2005 A study Ahwaz IRAN 10 pools 593 samples Aspergillus spp Penicillium spp Mucor spp (most common) + dermatophytes 372 saprophytic fungi species and 32 yeasts Rafiei ARafiei A.,2010 A study Assiut, EGYPT2 POOLS, 50 SAMPLES Trichophyton terrestre, 14% Most common keratinolytic fungi 8 species in total Maghazy SMMaghazy SM, 1989 PALESTINEPOOLSAcremonium strictum Cladosporium cladosporioides (most common) 22 species in total Ali-Shtayeh MSAli-Shtayeh MS, 2002

Helminth and protozoan findings in the water of (Slovak) school swimming pools ( Totková A, 1994 ) Totková A Helminths Ascaris lumbricoides, Enterobius vermicularis and Taenia saginata, Protozoa Giardia intestinalis and Entamoeba coli. Samples water, walls of the swimming pool, equipment, sediment in filters. Conditions occurrence of parasites no. of swimmers

Viruses in recreational water‐borne disease outbreaks: a review Outbreaks by type of recreational water, n = 55. Sinclair, 2009 Outbreaks by an aetiologic agent, n = 55.

Echoviruses- meningitis CountrySourcePathogenCasesReference Connecticut, USACrowded swimming pool in camp ground Echovirus 931CDC, 2004 GERMANYnature-like swimming ponds echovirus 30215Hauri AMHauri AM, 2005 Case-control study ITALYPupils of 2 schools, but the source was a Pool + person to person echovirus 3068, an outbreakFaustini A Faustini A, 2006 (case-control study) ISRAELNo common source identified Swimming pool considered Echovirus 13128Somekh ESomekh E, 2003 (case-control study)

Enteroviruses- Adenoviruses CountrySourcePathogenCasesReference SPAINPharyngoconjunctival fever Swimming pool Adenovirus type childrenJ. Artieda, 2009 CYPRUS121 Pools, 5 citiesMany types + adenovirus 41 poliovirus Sabin 1 98% of the pools complied with regulations Bashiardes SBashiardes S, 2011 study

Vectors CountrySourcePathogenCasesReference KENYA115 water bodies car-track pools (n = 45) unused pools (n = 25) Anopheles, culicine immatures 38 water bodies positive. 63,5% of the positive were pools Impoinvil DEImpoinvil DE, 2008 Carlson JCarlson J, 2004

West NILE VIRUS Epidemic in Kern County, CA, when the human case annual incidence increased from 6-8 to 17 per 100,000, respectively. The 2007 increase in human infection was associated with contradictory surveillance indicators: severe drought, warm spring but cool summer, decreased rural and urban mosquito abundance but increased early season infection in urban Culex quinquefasciatus Say, moderate avian "herd immunity," and declines in the catch of competent (western scrub-jay and house finch) and non-competent (California quail and mourning dove) avian species. The marked increase in home foreclosures and associated neglected swimming pools increased urban mosquito production sites (Reisen WK et al. 2009)Reisen WK. Kern County’s West Nile Virus Strategic Response Plan: Fight the Bite campaign, which calls for reporting of neglected swimming pools

Adult female southern house mosquito, Culex quinquefasciatus Say, feeding. Photograph by James Newman, University of Florida.

World distribution of the southern house mosquito, Culex quinquefasciatus Say. Illustration by Stephanie Hill, University of Florida.

West Nile Virus Greek epidemic YEARCASESDEATHS

ASSESSMENTS COUNTRYSTUDYRESULTSREFERENCE GREECE 60POOLS % “fail” Blougoura and Mavridou, 2011 SPAIN 4 NATURAL POOLS 3/4 failed the standards Lack of specific regulation Casanovas-Massana 2011 Milan ITALY Public swimming pools Non-compliance 72.3% % Tesauro MTesauro M, 2010 Alexandria EGYPT environmental health aspects 1. Swimmers using head caps : 30.1% 2. Some people enter the pool with private clothes Abdou MHAbdou MH, 2005

Opportunistic pathogens Παιδικές πισίνες Πισίνες υδροθεραπείας Spa pools Πολλαπλής χρήσης (θεραπεία και γενική χρήση)

Pool waters as a potential route of transmission of opportunistic pathogens to bathers FUNGI Aspergillus nidulans Phoma Rhodotorula minuta Acremonium Trichoderma Geotrichum Penicillium spinulosum (Boutsi & Mavridou Porto, 2011) BACTERIA Aeromonas hydrophyla Brevundimonas vesicularis Brevundimonas diminuta Burkholderia cepacia Sphingomonas paucimobilis Chryseomonas luteola Pseudomonas stutzeri Pseudomonas fluorescens Serratia ficaria Ch. indologenes Moraxella spp St. maltophilia

Molecular identification of potential pathogens in water and air of a hospital therapy pool investigation of bioaerosols generated by warm-water pools and their appurtenances. M. avium complex The results of the study strongly validate aerosol partitioning as a mechanism for disease transfer in these environments. The results also show that culture protocols currently used by public health facilities and agencies are seriously inadequate for the detection and enumeration of potential pathogens. (Angenent, PNAS (USA), 2005)

Microsporidia They are considered as the 4th most prevalent protozoans causing diarrhoeal disease. Immuno-compromised persons are at highest risk of severe disease. Infections – enteric – cornea – kidney – central nervous system Barna & Kadar, 2012

ΦΥΣΙΚΕΣ ΠΙΣΙΝΕΣ Aντικατάσταση επεξεργασιών με φυσικά συστήματα Ψευδαίσθηση φυσικού περιβάλλοντος Περιβάλλεται από ζώνη αναζωογόνησης Επιλέγονται φυτά που αποδομούν Ν, P Eμπλουτισμός με σαπροφάγα, ασπόνδυλα Εν ανάγκει προστίθεται ζώνη με φίλτρα Απουσία ειδικής νομοθεσίας, σε κάποιες χώρες μερικές ρυθμίσεις Μεγαλύτερη καταγεγραμένη επιδημία στοKassel, 2001, ιογενούς μηνιγγίτιδας.

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Μελλοντικές εξελίξεις WHO Guidelines Toυρισμός (κυρίως εξωτικός) και πισίνες Εννιαία Ευρωπαϊκή Νομοθεσία