Hot tubs – healthy or unhealthy choice?
Part 2

Published July 1, 2009

by Frank Rosa
President
Aqua Technical Services Inc.

In the first installment we discussed the history and benefits, now we will look at additional threats to health.

Is Legionella the only threat? No! Thirty-two of sixty-one persons who had used the swimming pool and whirlpool at a Minnesota motel in March 1975 came down with Pseudomonas aeruginosa serogroup 11. This was isolated from the skin lesions of two of the cases and from the water from both pools. In 1997, two boys came down with Hepatitus A after playing in a spa.

Let’s look at Eczema Herpeticum (non-venereal herpes). The literature outlines the case of a 10-year girl who developed the illness after sitting in a Hot Tub with a friend who had cold sores. “Several health spas were closed temporarily because of possible nonvenereal spread of herpes simplex virus (HSV) in spa water at these facilities. HSV could not be isolated from the spa water specimens, however, survival of significant amounts of virus for 4.5 hours on plastic surfaces suggests that fomites such as these may be nonvenereal routes of HSV transmission.”

Why don’t the “health authorities” do something? First, illness has to be reported to them. More often than not, it is not. It also hinges on the departments expertise in the field of waterborne illnesses and its budget allocation for field and lab work. A case in point, in the 10462 zip code of the Bronx, New York City, New York, Parkchester/Castle Hill neighborhood, there were 27 cases of Legionnaires’ Disease – four times the citywide rate in 2006. This is not to say that cases were from Hot Tubs, only that overburdened health authorities had more important things to do. Two cases at a major hotel in midtown Manhattan would have caused a major panic.

Many will downplay the dangers of the illness, treating 3000/month upper respiratory ills as Community Acquired Pneumonia (CAP) , but not the victims, especially the ones that succumb. A study was done in Germany that showed Legionella was the second most prevalent infection in a CAP population. Is Legionnaire’s Disease a real threat, one victim, a Cath Lab Nurse (RN), tells her story :

“It was a relaxing soak in a Hot Tub on a romantic trip to a beachfront hotel in Marina. Little did Stacy Intille know it would almost cost her her life. Five days after returning to her Sacramento home in September 2001, the Registered Nurse fell ill with flulike symptoms. Within days, she was admitted to the intensive care unit and placed on a ventilator with severe pneumonia. Knowing the incubation period for Legionella bacteria is two to 10 days, Intille and her doctors traced her illness to her stay at the Marina Dunes Resort, where Intille, 37, and her boyfriend had soaked in a private soft tub on the balcony of their suite.

“I’m trying to balance public health issues with making sure (King) comes into compliance in a reasonable time frame,” said Curt Batson, San Luis Obispo County environmental health director. “There’s a cost involved and I want to be reasonable here. In the 32 years I’ve been in this business, I’ve only heard of one case of (spa-related) Legionnaire’s disease.” - one hears this mantra repeatedly, leaving one wondering if the “experts” bother to read medical and other Journals related to illness.

Did hotel/motel owners heed? “One hundred and fifteen people are believed to have been affected by the Legionnaires’ disease bug in an outbreak at a Sunderland Leisure Club…The Health Protection Agency traced the outbreak last year to faults in the water treatment system at the Springs Health Club, which led to the legionella pneumophilia bug colonizing the spa pool system. It is now known that the 115 people became ill after visiting the leisure club from August 11 to 25 last year.” Surely, by now, it would have hit home, the following from a colleague:

“Monday, July 9,2007. On my way home from a trip a week ago I stayed at a well known hotel chain (usually very nice) and saw the spa’s Hot Tub. It looked very filthy, and I eventually took some swabs to bring home. The tub was indoors and was used by about a dozen different people during the few hours I observed it. Usually we have to enrich for cultures to work with, but with this one, it already looked like a rich culture, directly!! It had several species of ciliates and even 2 of Colpoda, which are usually outdoor pond and vegetation organisms. There were several species of flagellates swimming like crazy. There were just heaps of amoebae of several species. It really looked like our cultures fed high levels of bacteria. There were also rafts and rafts of clumps of bacteria...yuck!! I’ve sampled several Hot Tubs before, and even found novel bacterial species infecting amoebae from them, but we hadn’t seen the amoebae directly as we did with this one. . . I did mention that I was a research microbiologist who specialized in Hot Tubs and cooling towers, and that they should consider this as a potential problem. I haven’t heard back from the chain yet…”

From the UK, “Third case of Legionnaires’ Disease confirmed, Published: July 2007
A third person has tested positive for Legionnaires’ Disease after staying at Mackay’s Hotel, Strathpeffer and using the Jacuzzi on the weekend of June 16-17.” There were five cases in total. ,

A parting shot from this adverse perspective “UK - A Health Protection Agency study has highlighted serious problems with spa pools being a cause of Legionnaires’ …The yearlong study, surveyed over 100 spa pools,… Out of 88 premises, 23 spa pools were found to contain legionella bacteria…Dr Susanne Surman-Lee, who led the research said, “In every spa pool related outbreak that we have investigated the pool had not been managed or designed according to guidelines or had poorly trained staff. In addition, at present, testing for legionella is not mandatory for spa pools… During 2003, there were 27 cases of Legionnaires’ disease in England where spa pools were identified as the source of infection, with three deaths.

What about indoor, heated, therapy swimming pools? The same would apply, more so if the pool is used in a health care facility, due to health of persons using it. The issue of Methicillin-resistant Staphylococcus aureus, (MRSA), Penicillin-Resistant Enterococcus (PRE), Vancomycin-Resistant Enterococcus (VRE), and Linezolid-Resistant Enterococcus (LRE) must always be at the forefront in decisions to use such facilities. See footnote for additional information.

We know the illness, the threat and the reality, how are they addressed?

…The last installment will present methods used to cope with the problem and the realities of the microbial world.

1 Washburn John. JAMA 235: 2205-2207, 1975
2 Melburn, Australia, 1997
3 (Cox GF, Levy ML, Wolf JE Jr Pediatr Dermatol 2 (4): 322-323 (Jul 1985)
4 (Nerurkar LS, West F, May M, Madden DL, Sever JL JAMA 250 (22): 3081-3083 (Dec 9 1983)
5 NY DAILY NEWS, Thursday, July 26, 2007 by Bill Egbert
6 Private communication from Hong Kong
7 Researchers Identify Characteristics of Patients With Legionella Spp. Community-Acquired Pneumonia: Presented at ECCMID-ICC, By Chris Berrie, MUNICH, GERMANY -- April 10, 2007 -
8 Relaxing spa, deadly menace, Nurse on a mission after barely surviving Legionnaire’s disease, by Virginia Hennessey, Herald Salinas Bureau
9 Legionnaires’ bug hit 115 people at spa club Jul 13 2007, by Graeme Whitfield, The Journal (UK)
10 Personal communication relating to CODES
11 FOURTH VICTIM OF LEGIONNAIRES’ BUG, 08:50 - 07 July 2007, The Press and Journal, North Scotland, UK
12 MEDIA RELEASE, USE: Immediate, ISSUE DATE: 27/07/07, NHS Highland
13 Spa pools a cause of legionnaires’ disease, UK, News, Article Date: 14 Sep 2004 http://www.hpaconference.org.uk
14 http://en.wikipedia.org/wiki/Antibiotic_resistance