Oh, the power of suggestion of running water…the overwhelming sense of urgency elicited. The little boy in this year’s TaxACT Super Bowl XLVI commercial is in the family swimming pool when he realizes he has to go! He tries to do the right thing: He leaves the pool and dashes through the house in search of an open bathroom. But luck is not on his side. Every bathroom is occupied and to make matters worse, as he races from room to room, the little guy is tormented by the sight of water streaming from the washing machine and steam shooting from the tea kettle. Desperate, he plunges back into the pool where relief floods his face. Yes, he pees in the pool. But he tried valiantly to avoid it.

In 2009 the Water Quality & Health Council conducted a public survey that found one in five American adults admit to having peed in a pool. The news made headlines and focused attention on this unsanitary practice.

Peeing in the pool is a lose/lose proposition because:

• Swimmer urine depletes chlorine that would otherwise be available to destroy waterborne germs.
• Chlorine reacts with urine to produce compounds called chloramines that irritate the eyes and skin of swimmers.

At the end of the commercial, the boy appears smug with the knowledge that he has tainted the pool for his sister. The truth is that no one wins when pool water quality is degraded.

Speaking of winning, it is estimated that over 111 million people viewed the Super Bowl commercials as the Giants out-battled the Patriots in the big showdown. While fans were surely amused at the comical conclusion of the TaxACT commercial, let’s hope many of those viewers will be as motivated as our little protagonist was to get out of the pool the next time the urge strikes—and return only after using the bathroom.

Chris Wiant, M.P.H., Ph.D., is president and CEO of the Caring for Colorado Foundation. He is also chair of the Water Quality & Health Council.

In the case of private well water that undergoes no treatment at all, taste and odor are simply a function of the presence of naturally occurring minerals and organic matter in the locally tapped groundwater. Municipal treatment, however, adds another level of “complexity” for the palate.

According to the American Water Works Association (AWWA), “ultra-treated” water is disagreeable. Distilled water, for example, which is pure water with no dissolved components, tastes flat, bitter, and astringent. (You would know this if you have ever tasted distilled water sold for steam ironing.) That’s because our mouths are accustomed to the pH and mineral content of our saliva, which are quite different from those of distilled water.

A refreshing glass of drinking water requires certain chemicals be present in combination, such as calcium and bicarbonates. And a drink of water that originated from a municipal treatment plant probably made contact with chlorine when it was added to destroy waterborne germs, such as e. coli 0157 H7 and norovirus, which are capable of spreading disease. Chlorine disinfectants play an essential role in maintaining the public health, but they can introduce an unpleasant odor or taste to drinking water.

Smells Like Chlorine

The chlorine odor of tap water can be traced to the chlorine “residual,” a low level of chlorine maintained in water to guard against bacteria, viruses and parasites, which may be in water as it flows from the treatment plant to points of use. In the US, even treatment plants that use non-chlorine disinfection technologies are required to add chlorine to the water before it flows into the distribution system. The chlorine residual acts like a “body guard” for water in transit. As long as there is a residual level of chlorine, the consumer is reasonably protected from harmful microorganisms.

According to the AWWA, if the chlorine residual level is sufficient without being excessive, water will not smell like chlorine. Yet, sensitivity to the odor of chlorine varies among consumers. The US Environmental Protection Agency (EPA) requires treatment facilities to maintain a chlorine residual level that is chemically detectable but no greater than 4 mg/l. Four milligrams per liter is the “Maximum Residual Disinfectant Level” for chlorine, and it is the level below which there are no known or expected risks to health from exposure to the disinfectant.

Most people can sense a chlorine residual around 1 mg/l. If your water smells strongly of chlorine, it is possible that your treatment facility conveys water over a long distance, requiring heavy chlorination to maintain a chlorine residual throughout the system. (The chlorine residual also may be raised by treatment facilities during warm weather when chlorine dissipates readily from water.) AWWA notes that this can be remedied by systems reducing chlorine added at the point of entry and installing booster chlorination systems in the distribution line. The consumer also has practical options (see text box).

Consumer Confidence Report

Do you have a question about your drinking water quality? If your home is served by a community drinking water system, you should receive a consumer confidence report (CCR) from your water supplier each year by July 1. A CCR provides a general overview of the water quality delivered. This EPA website contains links to some drinking water systems reports and a Frequent Questions section. If you still have questions, contact your water supplier.

Linda Golodner is President Emeritus of the National Consumers League and Vice Chair of the Water Quality & Health Council.

Norovirus is a highly contagious virus that causes flu-like symptoms of nausea, vomiting, diarrhea and abdominal cramping.

(Image from CDC website)

The dreaded “stomach flu” that hits particularly hard in winter is not a flu at all. It is norovirus, a highly contagious virus that causes symptoms of diarrhea, vomiting and stomach cramping. According to the Centers for Disease Control and Prevention (CDC), the illness often begins suddenly and lasts for one to two days with no long-term adverse health effects. True “flu” is a respiratory disease caused by the influenza viruses; sometimes the “true flu” can also cause gastrointestinal symptoms similar to norovirus. Getting an annual flu vaccine can help prevent flu; unfortunately, there is no vaccine for the norovirus and antibiotics, useful only for bacterial infections, do not help.

Norovirus is extremely common and has gained notoriety as a vacation cruise spoiler and an unwelcome visitor in child and adult care facilities, schools, restaurants, hospitals and dormitories. Norovirus particles are extremely small and are discharged by the billions in the stool or vomit of infected people, according to CDC. Yet, fewer than 100 virus particles are highly likely to make a person sick. The virus spreads through direct contact with an infected person or when an individual touches a contaminated surface and then touches their mouth or even their nose.

A 2011 study found norovirus is the leading cause of foodborne illness in the US, responsible for 5.5 million cases each year. In many cases, sick food handlers are responsible for these outbreaks. Eating foods contaminated with norovirus is a leading cause of hospitalizations.

Recipe for an Outbreak

Close quarters and a breakdown in sanitation is the simple recipe for a norovirus outbreak. Attention to surface disinfection is critical to controlling the spread of norovirus. Proper hand washing is another “must” as the virus can be transmitted easily via contaminated hands. It is important to know that a norovirus carrier can infect others for at least three days after recovery.

These steps, from CDC, can help reduce your risk of contracting norovirus:

• Wash your hands carefully with soap and water, especially after using the toilet and changing diapers and always before eating or preparing food.
• Carefully wash fruits and vegetables, and cook oysters and other shellfish thoroughly before eating them.
• If infected with norovirus, do not prepare food for others while experiencing symptoms and for three days after recovery (see Norovirus: Food Handlers).
• After throwing up or having diarrhea, immediately clean and disinfect contaminated surfaces by using a solution made with chlorine bleach and water:

Disinfecting against Norovirus with Chlorine Bleach

• Immediately remove and wash clothing or linens that may be contaminated with vomit or stool. Handle soiled items carefully—without agitating them—to avoid spreading the virus. If available, wear rubber or disposable gloves while handling soiled clothing or linens and wash hands after handling. Soiled items should be washed with detergent at the maximum available cycle length and then machine dried.

Joan Rose, PhD, is the Homer Nowlin Chair in Water Research at Michigan State University and a member of the Water Quality and Health Council.

¹http://emergency.cdc.gov/disasters/disease/pdf/diarrhea-evac.pdf
²http://health.utah.gov/epi/diseases/norovirus/Guidelines_for_Environmental_Cleaning_125846_7.pdf

Eight people who walked by just such a water wall in a Wisconsin hospital lobby in 2010 are believed to have contracted the disease by inhaling the mist from the streaming water. Legionella can affect people whose immunity may be depressed due to an underlying illness, or due to a medication regimen; smokers may also be vulnerable. One of the patients affected in Wisconsin was a delivery person who had been a smoker and had made two deliveries to the hospital. Others had visited the pharmacy adjacent to the water wall to obtain medications.

The outbreak is an unintended consequence of well-intentioned efforts to create a soothing and welcoming healthcare environment. For now, we know those decorative water walls are a bad idea unless sanitary conditions are meticulously maintained.

Legionella under the Rocks

A new study published in the journal Infection Control and Hospital Epidemiology notes that although the decorative water wall underwent routine cleaning and maintenance, the bacterium Legionella pneumophila found a niche at the base of the water wall. The bacterial breeding ground was identified as a bed of sponge-like foam installed under decorative rocks to prevent water splashing.

In a January 11, 2012 interview with National Public Radio, the study’s lead author, Dr. Thomas Haupt, a respiratory disease epidemiologist for the Wisconsin Division of Public Health, was asked whether chlorine in the water would have prevented the outbreak. Haupt replied that chlorine in the atrium of a hospital “would have caused a lot of smell.” Haupt also described what seems to have been a “perfect storm” for Legionella contamination: Lights installed under the foam material in the trough and the trough’s close proximity to a fireplace helped provide a warm environment highly conducive to Legionella growth.

Haupt’s study notes the Wisconsin outbreak is the second example of Legionnaires disease associated with a decorative fountain in a healthcare setting. (The first example occurred in 2007.) The Wisconsin Department of Public Health has developed interim guidelines advising healthcare facilities with similar water walls or fountains to “establish strict maintenance procedures and conduct periodic bacteriologic monitoring to assess levels of Legionella.”

Fortunately, all eight Wisconsin patients recovered from Legionnaire’s disease and the hospital water trough has been converted into a planter. Going forward, let’s either use the tools we have to keep Legionella in check in decorative water walls, or keep them dry.

Jerod M. Loeb, Ph.D. is Executive Vice President, Healthcare Quality Evaluation at The Joint Commission in Oakbrook Terrace, Illinois.

Chlorinated wash water used during cantaloupe processing can help reduce the risk of foodborne illness to consumers.

Last summer a family-owned farm in Colorado became the focal point of the largest foodborne illness outbreak in the US in 25 years. Tragically, cantaloupe contaminated with Listeria bacteria sickened 146 people in 28 states, killed 30 and caused one pregnant woman to miscarry, according to the Centers for Disease Control and Prevention (CDC). The US Food and Drug Administration (FDA) concluded the outbreak likely could have been prevented if Jensen Farms had maintained its facilities in accordance with existing voluntary FDA guidance. FDA has no enforceable regulations on cantaloupe processing, and farm facility auditors conducting inspections do not consider FDA voluntary guidance when scoring facilities. Scores can be lowered only if practices are inconsistent with FDA regulations. That could, and should, change.

Recently the House Committee on Energy and Commerce released a report outlining multiple operational problems contributing to the cantaloupe contamination. The investigation report notes FDA officials were “highly critical of the processing methods used at Jensen Farms,” and emphasized two probable causes of the contamination: a change in processing equipment and a decision not to chlorinate cantaloupe wash water. In 2011, after 20 years of cantaloupe production with no reported food safety problems, these decisions helped spell disaster at Jensen Farms.

Deadly Decisions

Eric and Ryan Jensen inherited Jensen Farms upon the recent death of their father. Ironically, the House Committee report states that during an August, 2010 safety audit, one of the Jensen brothers expressed interest in improving their processes. The auditor suggested the Jensens consider replacing the hydrocooler, which sprays water on cantaloupes to cool the harvested fruit. The auditor considered the hydrocooler a “hotspot” due to its recirculating water. Believing they were strengthening their food safety efforts, the Jensens purchased and retrofitted equipment previously used to process potatoes. The House Committee cited FDA’s characterization of this equipment as “inappropriate” and “difficult to clean.” Listeria was later detected on the felt roller brushes of this processing equipment.

Up until 2011, Jensen Farms followed FDA voluntary guidance with regard to using antimicrobial solutions, such as chlorine, in cantaloupe wash water. Disinfectants are added routinely to produce wash water to help destroy pathogens like Listeria. This measure is particularly important for cantaloupe with its convoluted outer surface that can harbor moisture and bacteria. According to the House Committee report, the Jensen brothers discontinued this precaution in 2011, a fact that was noted on the front page of that year’s audit report. No reason was given for this process change, and Jensen Farms received a glowing audit score because scores are not based on adherence to FDA voluntary guidelines.

Going Forward

According to the House Committee report, the cantaloupe distributor for Jensen Farms, Frontera Produce, is working with NSF International, a standard-setting organization, and other firms to improve the current audit system. Additionally, the new Food Safety Modernization Act requires FDA to establish an accreditation system and model auditing standards. These measures should be taken without delay to prevent a repeat of the preventable tragedy that started last summer at Jensen Farms. We’ll be watching…

Chris Wiant, M.P.H., Ph.D., is president and CEO of the Caring for Colorado Foundation. He is also chair of the Water Quality & Health Council.

• 2011-2012 Flu Season: So Far, So Good
  Centers for Disease Control and Prevention (CDC) flu prevalence maps indicate flu season is off to a slow start. But don’t be complacent: Flu activity most often peaks during the month of FEBRUARY.

• Flu Season is Unpredictable
  In the U.S., on average, 5 -20% of the population gets the flu each year, and more than 200,000 people are hospitalized from seasonal flu-related complications. According to CDC, flu seasons are unpredictable and can be severe. Just because you have never had the flu doesn’t mean you won’t get it this year.

• Flu Risk by Zip Code?
  One study correlated the percentage of children in a given zip code with the risk of ending up in the Emergency Room with the flu. Preventing the spread of flu in children may be an important factor in slowing a flu epidemic. Experts recommend that everyone six months and older should get a flu vaccination each year.

• Vaccination Statistics
  According to CDC, the best way to prevent seasonal flu is by getting a flu vaccination each year. As of November, 2011, only approximately 36% of Americans age six months and older had obtained a flu vaccination (CDC). Most individuals are vaccinated in doctor’s offices; other popular locations are other healthcare settings, pharmacies and stores, and the workplace.

• Vaccine Protection
  The 2011-2012 vaccine is a three-component vaccine that protects against each of three main groups of influenza viruses currently circulating in humans. According to CDC, based on a recommendation from the World Health Organization, the Northern Hemisphere’s 2011-2012 seasonal influenza vaccine contains the following three vaccine viruses:

  An A/California/7/2009 (H1N1)-like virus
  An A/Perth/16/2009 (H3N2)-like virus
  A B/Brisbane/60/2008-like virus.

• A Reason to Practice Flu Prevention
  On average, flu-related complications claim 36,000 lives each year in the US in one study, according to CDC. These rates can range from a low of approximately 3,000 deaths to a high of about 49,000 deaths according to another study. Anyone can get the flu, but some people are at higher risk of developing serious flu-related complications. These include: people 65 years and older; people of any age with certain chronic medical conditions (e.g., asthma, diabetes, or heart disease), pregnant women and young children.

• Flu or Cold?
  Flu and cold are not the same. Use this interactive chart of symptoms to help you distinguish flu from cold.

Ralph Morris, MD, MPH, is a Physician and Preventive Medicine and Public Health official living in Bemidji, MN.

“Clostridium difficile,” is a spore-forming bacterium that can live in the lower gastrointestinal tract of some humans and is shed in feces. Persons hosting C. diff may have no symptoms and be unaware that they are contagious. Other persons will become infected under specific circumstances. A C. diff infection may produce watery diarrhea, fever, loss of appetite, nausea or abdominal pain and tenderness. According to the Centers for Disease Control and Prevention (CDC), patients who are at increased risk for infection include those who:

• are taking antibiotics
• have had gastrointestinal procedures
• have had a prolonged stay in a healthcare institution
• have a serious underlying illness
• are of an advanced age.

Any surface or medical device that becomes contaminated with feces may serve as a reservoir for C. diff spores including toilets, bathtubs, or electronic rectal thermometers. In the healthcare setting, the spores are thought to be transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. Dr. Robert Orenstein, of the Mayo Clinic Arizona, calls C. diff infection “a significant threat to our public health”. His goal is to reduce the risk of C. diff infection by reducing environmental contamination and he has a strategy that just might work.

A Tale of Two Hospital Units

In a 2011 publication Dr. Orenstein describes a study in which two high-risk hospital units were targeted for daily cleaning of high touch surfaces with germicidal bleach wipes (in addition to terminal cleaning after a patient is dismissed). The researcher chose bleach wipes because a 10 percent solution of hypochlorite bleach destroys the spore form of C. diff. The study showed that over a six-month period the units experienced a 92 percent decline in hospital-acquired C. diff infection! This result was achieved without any other interventions, such as increased attention to hand hygiene. Further, Dr. Orenstein reports, the results were sustained for over one year with only two infections in 12 months. Meanwhile, infection rates in other units in the study hospital remain high.

To implement these effective risk reduction measures, environmental service staff were trained in proper use of bleach wipes. Housekeepers worried about the irritating effects of bleach were given plain surgical masks and ventilation was ensured. As the study progressed, patient and employee tolerance of the wipes was monitored and found to be satisfactory. Orenstein notes no reports of equipment damage; keyboard covers, however, “often had a haze after the product dried on them.” A wet cloth applied to the covers removed the haze, which is a salt residue.

Dr. Orenstein’s study provides importance evidence to help destroy C. diff—a significant hospital public enemy found on surfaces in healthcare settings. Healthcare officials should consider adopting a bleach disinfection strategy for daily and terminal cleaning, a step that could help decrease the risk of serious infection.

Barbara M. Soule, R.N. MPA, CIC, is an Infection Preventionist and a member of the Water Quality & Health Council.

This holiday season the Water Quality & Health Council hopes you will enjoy the good cheer of family and friends. Seeing the little ones is one of the special joys of the season. Naturally, we want them to be healthy and avoid the colds and flu that seem to run rampant at this time of year.

One of the best lessons we can teach children about staying healthy is the importance of hand washing.

Here’s a fun coloring page from the American Cleaning Institute® that just may help turn the little folks in your life into budding public health experts:

Clean Your Paws for Santa Claus Coloring Page

Click on the link above to download the coloring page.

Neti pot¹ use is being blamed for the deaths of two Louisiana residents who developed a rare fatal brain infection after using the device to clear their sinuses (The Advocate article). The infections are believed to have been caused by the water-dwelling parasite, Naegleria fowleri. According to the Centers for Disease Control and Prevention (CDC), Naegleria may be present in warm lakes and rivers and geothermal waters, such as hot springs and natural spas. It can also live in inadequately chlorinated swimming pool water. If the parasite is inadvertently inhaled and migrates from the human nose to the brain, it can cause “amoebic meningoencephalitis” and almost certain death. People cannot be infected with this parasite by drinking water.

Neti pot users circulate warm saline water through the nostrils; if water is contaminated with Naegleria, which appears to have been the case for two unfortunate people in Louisiana, the result can spell tragedy. In the case last June of one victim, a young man in his 20s, the infection was traced to the man’s home water system even though the parasite was not found in city water samples. More recently a 51-year old Baton Rouge woman succumbed to the brain infection caused by Naegleria. These cases are troubling, and we anticipate more information will be forthcoming as a result of further investigation.

Naegleria: Rare but Deadly

The Louisiana Department of Health cites statistics that demonstrate how rare Naegleria infections are: Between 2001 and 2010, 32 infections were reported in the US, most in southern states and mostly during summer, particularly during extended heat waves. Of the 32, 30 were caused by contaminated recreational water and two resulted from contact with a geothermal water supply. Updated statistics will include the recent deaths associated with neti pots.

What You Should Know about Naegleria

The greatest risk to humans of Naegleria is its inadvertent inhalation in contaminated water, usually through two routes:

Contact with recreational waters:

• When swimming in freshwater lakes and rivers, particularly in the South, nose clips can be worn to prevent inhaling infected water. Caution should also be exercised around geothermal waters. The CDC recommends avoiding water-related activities in warm freshwater during periods of high water temperature and low water levels. It is best not to dig in or stir up sediment while taking part in water-related activities in shallow, warm, freshwater areas.
• Swimming pools must be adequately disinfected to destroy Naegleria and other waterborne pathogens. The CDC and the Water Quality & Health Council recommend swimmers use pool test kits to check pH and free chlorine levels of chlorinated pools before swimming. If readings are out of the appropriate range (pH between 7.2 and 7.8; free chlorine level between 1 and 3 parts per million), a pool manager should be notified. If pool chemistry is not properly adjusted, the local public health department should be contacted.

Net pot use:

• When using a neti pot, follow directions for preparing saline water solutions. A December 6 press release issued by the Louisiana Department of Health and a CDC online resource urge neti pot users to use distilled, sterile or previously boiled water (least expensive option) to make up the irrigation solution.
• Clean and disinfect neti pots after use. After washing with soap and water, rinse with a solution of ½ tablespoon of chlorine bleach added to ½ gallon of water and allow to air dry.

News of rare Naegleria infections is not cause for alarm, just reason to be well-informed. We pledge to follow this issue and keep you updated.

Barbara M. Soule, R.N. MPA, CIC, is an Infection Preventionist and a member of the Water Quality & Health Council.

For more information on disinfecting surfaces, please go to www.disinfect-for-health.org.

For more information on disinfecting pools, please go to www.healthypools.org

This year 43 percent of Americans plan to be immunized in hopes of warding off the flu, according to an interclick survey reported in Infection Control Today. The survey found more women (46%) than men (38%) will roll up their sleeves for the shot this year. Men would be well-advised to be immunized, however. Based on the interclick survey responses, doing so could potentially preserve marital peace. The Walgreens report noted one-third of women respondents think their spouse is very annoying or “a nightmare” when sick, while only 14 percent of men feel the same way.

What is the flu?

Influenza (the flu) is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death. The 2011-2012 flu vaccine was developed to protect against the three influenza viruses that research indicates will likely be most common during the current flu season. This includes the 2009 influenza A (H1N1) virus, an influenza A (H3N2) virus, and an influenza B virus.

Flu can peak anytime between October and April in the US, according to Walgreen’s chief medical officer, Cheryl Pegus. According to the U.S. Centers for Disease Control and Prevention (CDC), vaccination before December is best since this timing ensures that protective antibodies are in place before flu activity is typically at its highest.

Who should be vaccinated?

According to CDC, everyone should get a flu vaccine each flu season, but it is especially important that the following groups be vaccinated:

• Pregnant women
• Children 6 months old and older
• People 50 years old and older
• People of any age with certain chronic medical conditions
• People who live in nursing homes and other long-term care facilities
• People who live with or care for those at high risk for complications from flu, including
  • Health care workers
  • Household contacts of persons at high risk for complications from flu
  • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)

So,

• Try to minimize contact with others who are ill
• Wash your hands to reduce the spread of germs
• Disinfect commonly touched surfaces
• Stay home from work or school if you are sick and…

Help preserve your holiday vacation, your health and your marriage: Get a flu shot!

Ralph D. Morris, M.D., M.P.H., (of Ralph’s Closet Fame), is a semi-retired physician in northern Minnesota working as the Medical Director for Greater Northwest EMS and teaching online epidemiology at the University of North Dakota.

For more information on flu, please see www.fluandhealth.org.