World No-Tobacco Day is May 31, 2001. The theme, "Second-Hand Smoke Kills-Let's Clear the Air," was designated by the World Health Organization (WHO) to raise awareness of the hazards of exposure to second-hand smoke. Tobacco use worldwide will cause an estimated 10 million deaths annually by 2030 (1 ). An effective strategy to promote and encourage tobacco-free policies is to link them with sporting events. Such policies also reduce nonsmokers' exposure to second-hand smoke (2 ). The 1988 Olympic Winter Games in Calgary, Alberta, Canada, was the first tobacco-free Olympics. Since then, all of the Olympic Games have had tobacco-free policies (3 ). For the 2002 games, the Olympic organizing committee for Salt Lake City, Utah, will implement a public information campaign using Olympic athletes to promote healthy lifestyles and sports as an alternative to tobacco use. Plans also include information to increase awareness of the tobacco-free policy among visitors, media, athletes, and officials from participating countries. Another media campaign is "Tobacco Kills-Don't Be Duped," which aims to ban tobacco advertising and promotion at sporting events globally. Additional information about World No-Tobacco Day 2001 is available at *, and http:// www.cdc.gov/tobacco; telephone (800) 232-1311. References 1. World Health Organization. Combating the tobacco epidemic. World Health Organization's world health report 1999. Geneva, Switzerland: World Health Organization, 1999:6579. 2. CDC. National report on human exposure to environmental chemicals. Atlanta, Georgia:#
- Persons aged >18 years who reported having smoked >100 cigarettes in their entire life and who reported smoking every day or some days.  Confidence interval.  Significant value: two-tailed p<0.05.

# MMWR May 25, 2001
Tobacco Use Among Adults -Continued Asked about smoking and advised to stop smoking by a dentist? 9.9 (4.5) 24.9 (4.7)  - Persons aged >18 years who reported having smoked >100 cigarettes in their entire life and who reported smoking every day or some days.  Confidence interval.  Includes physicians, nurse practitioners, or physician assistants.  Significant value: two-tailed p<0.05. Asked of respondents who visited a dentist during the year preceding the survey. Editorial Note: The results of the 1996 and 1999 Arizona ATS indicate that the prevalence of cigarette use among Arizona adults decreased substantially following the implementation of the statewide Arizona TEPP. The decrease in smoking prevalence among low income and low education groups also indicates a narrowing in disparities in cigarette use.
TEPP directed many of its activities toward Hispanics, which may, in part, explain the substantial decrease in cigarette smoking in that population. TEPP serves the Hispanic population through its Spanish language statewide media campaign and telephone helpline and through local cessation and prevention services. TEPP uses methods appropriate for this population, including Promotoras de Salud (lay health workers) and culturally appropriate materials and curricula.
The Arizona ATS results also showed a substantial increase in the proportion of smokers who reported that either a health-care provider or a dentist both asked about tobacco use and advised them to quit. Health-care providers can play a key role in assisting MMWR 405
Tobacco Use Among Adults -Continued patients to quit smoking (2 ), and brief physician advice substantially increases successful quitting (2 ). TEPP, through statewide and local projects, provides training for healthcare providers to increase the number of patients with whom they briefly discuss stopping smoking. The findings in this report are subject to at least five limitations. First, it is difficult to separate the effects of TEPP from price increases. The cigarette tax in Arizona increased from $0.18 to $0.58 per pack in November 1994, which may have contributed to the decline in adult smoking prevalence. Although the tax increase occurred more than a year before the first survey, the average retail price of cigarettes in Arizona continued to increase from $2.08 in 1996 to $2.50 in 1999 (3 ). Second, some segments of the population in Arizona, including some low income residents, are more likely than others to lack telephone service and therefore not be included in the study sample. Third, the response rate in 1999 was almost nine percentage points lower than the response rate in 1996, which may have influenced the results. Fourth, health-care provider communication data about smoking was based on self-reported recall for an entire year; the validity of these self-reports was not determined. Finally, although declines in smoking rates in Arizona may be a result of TEPP, a cause-and-effect relation cannot be established by comparing data from the cross-sectional ATS surveys alone. Comparing Arizona smoking prevalence trends and trends in other states with varying levels of interventions during 1996-1999 could help to determine how much of the decline may be related to the Arizona TEPP rather than to regional or national influences.
Arizona is one of seven states that meet CDC's funding recommendations for FY 2001 (4,5 ). The Arizona TEPP incorporates all nine components of a comprehensive tobaccocontrol program as recommended by CDC (4 ). The program added a certification program for smoking cessation counselors. The Arizona TEPP has been implementing strategies recommended in the Surgeon General's report Reducing Tobacco Use (6 ), CDC's Best Practices for Comprehensive Tobacco Control Programs (4 ), the Clinical Practice Guidelines for Treating Tobacco Use and Dependence (2 ), and the Task Force on Community Preventive Services (7 ). The findings of the 1996 and 1999 Arizona ATS suggest that an adequately funded and comprehensive program can substantially reduce tobacco use overall and across diverse demographic groups. Recent reports from California indicate that sustaining such a program for at least 9 years also could result in reductions in lung and bronchial cancer and coronary heart disease rates (8,9 ). Attainment of the 2010 national health objective (10 ) to reduce adult smoking rates to <12% will require similar programs to be implemented across the United States.

# MMWR May 25, 2001
Tobacco Use Among Adults -Continued

# Protracted Outbreaks of Cryptosporidiosis Associated With Swimming Pool Use -Ohio and Nebraska, 2000
Swimming is the second most popular exercise in the United States with approximately 400 million pool visits annually (1 ). During the summer of 2000, five outbreaks of cryptosporidiosis linked to swimming pools were reported to CDC. This report summarizes the investigations of two of these outbreaks involving approximately 1000 cases and provides recommendations to reduce the transmission of pool-related disease.

# Ohio
In July 2000, the Delaware City/County Health Department (DCCHD) learned of several laboratory-confirmed cases of cryptosporidiosis potentially linked to a private swim club. To determine associated exposures, DCCHD, in collaboration with the Ohio State Health Department and CDC, conducted an investigation.
A descriptive study and two telephone-based case-control studies were conducted: a community-based study to examine potential sources of the outbreak and a swim clubbased study to identify club-related risk factors. Persons were asked about source of drinking water, recent travel, visits to pools and lakes, swimming behaviors, contact with ill persons or young animals, and day care attendance.
A clinical case was defined as diarrhea (three loose stools during a 24-hour period) in a person for at least 1 day. A laboratory-confirmed case was defined as diarrhea, vomiting, or abdominal cramps in a person and a stool specimen that tested positive for Cryptosporidium parvum. All case-patients were in central Ohio during June 17-August 18. Case-patients and controls were frequency matched by age. DCCHD identified 700 clinical cases among residents of Delaware County and three neighboring counties. The outbreak began in late June and continued through September (Figure 1). The club closed during July 28-August 4. Of 268 stool samples submitted to DCCHD, 186 (70%) tested positive for Cryptosporidium; 47 laboratory-confirmed casepatients were enrolled in the two case-control studies. The median age of these casepatients was 6 years (range: 1-46 years) and 28 (61%) were female. The median duration of illness was 7 days (range: 1-36 days). Symptoms included diarrhea (91%), loss of appetite (87%), abdominal cramps (83%), and vomiting (35%). Nearly half (45%) reported intermittent diarrhea. Swimming at the private club was strongly associated with illness in the community case-control study. Of the 47 case-patients, 40 (93.6%) went swimming in the pool, compared with 24 (55%) of 44 controls (odds ratio =42.3; 95% confidence interval =12. 3-144.9). In the club-based case-control study, activities that increased the risk for pool water getting in the mouth (e.g., standing under a pool sprinkler) increased the risk for illness (OR=8.4; 95% CI=1.8-54.8). At least five fecal accidents, one of which was diarrheal, were observed.

# Nebraska
In August 2000, the Douglas County Health Department, Nebraska, detected an increase in laboratory-reported cases of cryptosporidiosis. Initial cases were linked to a private club with swimming facilities (club A). Additional case-patients reported swimming at club A, at another nearby private club (club B), or at other local pools. The pools at clubs A and B subsequently closed for 2 weeks in mid-August.
A case-control study was conducted at club A to identify community and club-specific risk factors. A clinical case was defined as diarrhea (three loose stools during a 24-hour period) in a person who was a member of club A. A laboratory-confirmed case was defined as diarrhea, vomiting, or cramps in a person who had a stool specimen that tested positive for Cryptosporidium. All case-patients were in the Douglas County area during June 3-September 28. Members of club A with laboratory-confirmed or clinical cases of cryptosporidiosis were enrolled in the study. Controls were randomly selected from the club A membership list and frequency matched by age.
The outbreak began in mid-June, peaked in mid-August, and tapered off in September, coinciding with the end of the outdoor swimming season in Nebraska (Figure 2 Symptoms included diarrhea (94%), abdominal cramps (83%), loss of appetite (74%), nausea (60%), and vomiting (43%). The median duration of diarrhea was 7 days (range: 1-44 days), and nearly half (46%) of patients reported intermittent diarrhea. Thirty-seven case-patients and 36 controls were included in the case-control study at club A. Illness was associated with swimming at club A (OR=5.0; 95% CI=1.48-17.7) and having been splashed with pool water (OR=5.3; 95% CI=1.6-18.9).
Swimmers often swam at multiple pool facilities and swim/dive team meets were held at both clubs A and B. Approximately 18% of the case-patients reported swimming while symptomatic, and nearly one third (32%) swam either during illness or during the 2-week period after symptoms subsided. Fecal accidents were observed at both clubs. Editorial Note: Outbreaks of gastrointestinal illness associated with treated recreational water (e.g., swimming pools) appear to have increased in recent years with most being caused by Cryptosporidium (2,3 ). Although a fecal accident by a swimmer can expose other swimmers to various disease-causing organisms, the probability of transmission of cryptosporidiosis is higher in this setting for two reasons. First, Cryptosporidium oocysts are extremely resistant to chlorine and may remain infective for several days in swimming pool water containing recommended chlorine concentrations (4 ) and, because of their small size, may not be removed efficiently by conventional pool filters. Second, the high titer of Cryptosporidium in diarrhea from infected persons (5 ) and the low  6) make it possible for a single fecal accident to sufficiently contaminate an entire pool such that accidental ingestion of a few mouthfuls of water can result in infection.
The protracted nature of these two outbreaks highlights the challenges faced by health departments and pool managers in detecting and controlling pool-associated cryptosporidiosis outbreaks. The outbreaks went unreported for several weeks, possibly because ill persons often do not seek health care for diarrheal illness (U.S. Department of Agriculture, unpublished data, 1997). During this time, ill persons continued to swim, increasing the likelihood that contamination of the pools continued to occur. It is unclear whether extended pool closure reduced the potential for exposure or contributed to transmission at other pools. A multicomponent approach to outbreak prevention is needed that combines education of swimmers and pool staff, pool design modifications, and improved operations and maintenance procedures.
The high incidence of diarrhea in the United States (7 ) and the continued use of the pools during illness suggest that education of the public is an important component of any prevention strategy. To reduce pool contamination and the spread of cryptosporidiosis and other diarrheal illnesses, public health officials and pool managers should educate staff and patrons about key messages that may reduce recreational water illness transmission. To prevent transmission, persons with diarrhea should not swim, swimmers should avoid swallowing pool water, and persons should practice good hygiene before swimming, after using the restroom, and after changing a diaper.
Improved design and management of pools also may reduce the risk for disease transmission. Public health officials and pool operators should consider 1) using separate filtration systems for "kiddie" pools and other pools to decrease the potential for cross-contamination; 2) optimizing filtration rates of kiddie pools without facilitating suction injuries to decrease the length of time that swimmers would be exposed to pathogens; and 3) ensuring that restrooms and diaper changing areas are close to the pool and are clean and adequate in number. Management practices should 1) reinforce that pool operators regularly maintain and monitor pH and free residual chlorine levels to help prevent transmission of most waterborne pathogens; 2) develop policies for pool disinfection following a fecal accident (8,9 ); 3) train staff about prevention of recreational water illness transmission; and 4) institute frequent restroom breaks for young swimmers to reduce the potential for fecal accidents.
During a pool-associated or other local outbreak of cryptosporidiosis, extra vigilance is necessary to prevent swimming-related disease transmission. Those at risk for serious illness (e.g., immunocompromised persons) should consider not swimming during an outbreak. In addition, because persons ill with cryptosporidiosis often have intermittent diarrhea and Cryptosporidium can be excreted for several weeks after diarrhea subsides (10 ), ill swimmers should refrain from swimming while ill with diarrhea and should also not swim for a 2-week period after cessation of diarrhea. Operators of implicated pools should intensify education efforts and consider prohibiting diaper-and toddleraged children from swimming during the outbreak. In addition, health officials should alert pool operators in the geographic area so they can undertake intensive education efforts to prevent infected persons from swimming in and potentially contaminating their pools. Further evaluation is needed to determine the efficacy of extended pool closures on preventing Cryptosporidium transmission. Additional information about prevention of recreational water illness is available at .

# Prevalence of Parasites in Fecal Material from Chlorinated Swimming Pools -United States, 1999
As a result of the 1998 outbreak of infection with the chlorine-sensitive pathogen Escherichia coli O157:H7 at a waterpark in Georgia (1 ), many public health departments updated their guidelines for disinfecting pools following a fecal accident. Many of these guidelines recommended treating all fecal accidents as if they contained the highly chlorine-resistant parasite Cryptosporidium parvum (2 ), generally resulting in hyperchlorination and pool closures of up to a day. To determine whether fecal accidents commonly contained Cryptosporidium, the prevalence of this parasite and the moderately chlorine sensitive parasite Giardia intestinalis (3 ) was assessed by asking swimming pool operators throughout the United States to collect formed stools from fecal accidents in their pools. This report summarizes the results of this study and provides recommendations for disinfecting pools following fecal accidents.
During 1999, 47 swimming pools, waterparks, or aquatics centers were enrolled in the survey by telephone. Sample collection began Memorial Day weekend (May 29) and ended after Labor Day weekend (September 6). Samples of each fecal accident were collected into vials containing 10% formalin. Labels included no pool-specific identifiers. Samples were tested for Cryptosporidiumand Giardia-specific stool antigen without prior concentration. All positive specimens were verified using an immunofluorescent antibody mixture specific to Cryptosporidium and Giardia followed by microscopic identification.

# Parasites in Chlorinated Swimming Pools -Continued
None of 293 formed stools from fecal accidents collected by pool operators contained Cryptosporidium. Giardia was found in 13 (4.4%) of the samples. Because this study addressed parasite prevalence in only formed stool, no information relating to disinfection procedures for diarrheal fecal accidents was obtained. Editorial Note: During the 1990s, reports of outbreaks of gastrointestinal disease associated with the use of disinfected recreational water (i.e., swimming and wading pools, waterparks, fountains, hot tubs, and spas) have gradually increased (4 ). During 1989-1998, approximately 10,000 cases of diarrheal illness were associated with 32 recreational waterborne disease outbreaks in disinfected water venues in the United States. Ten outbreaks occurred during 1997-1998, the highest number of recreational water outbreaks ever reported (4 ). Because diarrheal illness is underreported to public health authorities, the number of outbreaks associated with recreational water use is probably higher (5 ). The number of swimming exposures in the United States (approximately 400 million annual visits) (6 ) and increasing attendance at high capacity recreational water venues provide strong incentives to review and improve recommendations to reduce the transmission of gastrointestinal illness resulting from recreational water use.
Because swimming typically involves sharing water with many other persons in a pool, the water contains various bodily fluids, fecal matter, dirt, and debris that wash off bodies during swimming activities. Fecal matter is regularly introduced into the water when someone has a fecal accident through release of formed stool or diarrhea into the water, or residual fecal material on swimmers' bodies is washed into the pool. Fecal contamination may be more likely to occur when there is a high density of bathers, particularly diaper-and toddler-aged children. Swallowing this fecally contaminated water is the primary mode for transmission of enteric pathogens in recreational water outbreaks.
Although chlorine is an effective disinfectant, it does not instantly kill all pathogens (7 ). In addition, some pathogens, such as the parasite Cryptosporidium, are highly resistant to chlorine concentrations routinely used in pools (2 ). Because of frequent fecal contamination, the inability of chlorine disinfection to rapidly inactivate several pathogens and the common occurrence of accidental ingestion of pool water, transmission of pathogens can occur even in well-maintained pools.
The low prevalence of Cryptosporidium in formed fecal accidents in this study indicates that regulators can adopt less stringent disinfection guidelines by disinfecting pool water as if it contained the moderately chlorine-resistant parasite Giardia. Although there is a large differential between inactivation times for Cryptosporidium, Giardia, and E. coli (approximately 7 days, <1 hour, and <1 minute, respectively, at 1 mg/L free available chlorine ), responding to formed fecal accidents with water treatment sufficient to inactivate Giardia also should be sufficient to inactivate other known viral and bacterial waterborne pathogens, including E. coli O157:H7 (8 ).
On the basis of these findings, CDC has prepared recommendations for responding to fecal accidents in disinfected recreational water venues (see Notice to Readers, page ). These recommendations assume the presence of Giardia in formed stool accidents and the presence of Cryptosporidium in diarrheal accidents. The prevalence of Cryptosporidium in diarrhetic and nondiarrhetic stools requires further investigation.
The Giardia inactivation guidelines are based on data developed by the Environmental Protection Agency for disinfection of Giardia in drinking water (9 ). Pool operators should consult with their local or state health authorities for specific fecal accident disinfection procedures. These recommendations are intended to minimize infectious disease transmission by observed fecal accidents (primarily formed stool); however, the unique circulation patterns found in pools often result in areas of poor pool circulation (i.e., "dead spots") making it unlikely that disease transmission can be fully prevented. In addition, the higher risk associated with diarrheal accidents, which may rarely be observed and/or responded to, makes it important that public health professionals and the aquatics industry address other critical recreational water illness prevention components. These may include improving aquatics industry policies, planning, and practices and educating aquatics staff and patrons about the potential for recreational water illness transmission. Swimmers should be informed by public health professionals and the aquatics industry that healthy swimming practices necessitate that patrons refrain from swimming while ill with diarrhea and avoid swallowing pool water. Improved hygiene before and during swimming (e.g., showering, handwashing, frequent restroom breaks for young children, and appropriate diaper changing) also should be promoted. Additional information about prevention of recreational water illness is available at / healthyswimming.

# Drowning -Louisiana, 1998
Drowning is the third leading cause of death from unintentional injuries in Louisiana. In 1998, the fatality rate from drowning for Louisiana residents was 3.1 per 100,000 population, higher than the U.S. rate of 1.9 per 100,000, and more than twice the 2000 national target of 1.3 per 100,000 population. This report describes the demographics and risk factors associated with drownings in Louisiana in 1998. Findings indicate that alcohol or illicit drug use was found in approximately 60% of tested victims aged >13 years and that none of the victims of boating-related drowning were correctly wearing a personal flotation device (PFD). Prevention efforts should focus on decreasing alcohol and illicit drug use and increasing the proper use of PFDs among boaters and others involved in water recreation.
The Louisiana Office of Public Health examined three sources of data on persons who died by drowning: 1998 death certificates, coroners' records, and records of investigations performed by the Louisiana Department of Wildlife and Fisheries (LDWF). A case was defined as death in a resident of Louisiana coded on the death certificate as having drowned in the state during 1998. Using death certificates, 137 cases were identified. Of these, 114 investigative reports were reviewed: 96 with coroners' records, six with LDWF reports, and 12 with both; investigative reports for 23 (17%) cases could not be obtained. In addition, modifiable risk factors were analyzed. Alcohol and illicit drug use were examined in the deaths of persons aged >13 years. Use was determined by the presence of ethanol or metabolites of illicit drugs in samples collected at autopsy. Among deaths that occurred in a swimming pool, pool fencing was described as present or absent, and PFD use was recorded for investigative reports of boating-related drowning.
Of the 137 drowning cases, 115 (84%) occurred among males. Blacks and whites died in almost equal numbers, 68 (50%) and 67 (49%), respectively; however, the rate of drowning among blacks was more than twice the rate of whites, 4.8 per 100,000 and 2.3 per 100,000, respectively. The median age of drowned persons was 32 years (range: 10 months-94 years). The highest drowning rate was among persons aged 25-35 years (3.8 per 100,000). Children aged <4 years accounted for 10% of the total deaths and had the second highest rate (3.5 per 100,000). Among those cases in which the manner of death could be determined, 122 (95%) were classified as "accident" (unintentional); seven (5%) were classified as suicide. Twelve (9%) drowning deaths were work-related.
Of 114 deaths with coroner or LDWF records, 83 (73%) occurred in natural bodies of water (e.g., lakes, bayous, rivers, and the Gulf of Mexico), 19 (17%) in swimming pools, and seven (6%) in bathtubs or hot tubs. Four deaths were classified to have occurred in an "other setting" and in one death the setting was unknown. Alcohol testing was recorded in 72 (76%) of the 94 decedents aged >13 years; 43 (60%) had evidence for the presence of alcohol and/or illicit drugs. Thirteen (30%) decedents were positive for alcohol and illicit drugs, 28 (67%) were positive for alcohol, and one (2%) was positive for illicit drugs.
Among the 19 deaths that occurred in a swimming pool, 11 (58%) were in children aged <14 years. Children aged <4 years died in swimming pools at the highest rate (1.3 per 100,000). The presence or absence of fences was noted in eight (42%) deaths. Six pools had and two did not have fencing. May 25, 2001

# Drowning -Continued
Coroner and LDWF reports indicated that 35 (31%) of 114 deaths occurred during boating-related activities: 11 (31%) involved a fall from the boat, seven (20%) occurred when the boat capsized, and six (17%) involved a collision. Five (14%) persons who drowned had entered the water voluntarily, and six (17%) had entered the water for unknown reasons. PFD use was recorded for 22 (63%) boating-related drownings; only one decedent had been wearing a PFD and it was unfastened. Among persons aged >13 years, 34 drownings occurred; 13 (48%) tested positive for alcohol or illicit drugs. Editorial Note: The circumstances of drowning identified in this report highlight ways to prevent drowning deaths. Drowning in Louisiana occurred most often in natural bodies of water. Approximately 30% of the deaths during 1998 were associated with boating, which is proportionately more than in the entire United States, where boating accounts for 20% of drowning (1 ). In this investigation, the findings indicated that alcohol or illicit drug use was present in nearly half of the tested boating-related deaths among persons aged >13 years, that none of the boating-related decedents had been wearing a PFD correctly, and that during 1998, drowning in swimming pools accounted for 17% of deaths, with children aged <4 years at highest risk. Louisiana state regulations pertaining to alcohol use focus only on boat operators, and state regulations on wearing PFD pertain only to children aged <13 years.
The findings in this report are subject to at least two limitations. First, some investigative reports were not available. Second, risk factor information was missing in many of the reports that were examined. Both of these limitations could effect the reported prevalence of risk behaviors.
By analyzing the state-level data described in this report, the Louisiana Office of Public Health determined that drowning prevention efforts should include: 1) decreasing alcohol and illicit drug use among both boating passengers and operators; 2) focusing on the proper use of PFDs not only among children but among persons of all ages; and 3) instructing caretakers to supervise children and maintain adequate fencing around swimming pools (2 ). For a pool fence to protect against drowning, the fence must completely enclose the pool and must be at least 4 feet high with vertical openings <4 inches wide and with a functional self-latching gate (3 ). All of these prevention efforts need to be delivered in a manner culturally appropriate for the highest risk populations.

# Notice to Readers

# National Safe Boating Week -May 19-25, 2001
National Safe Boating Week is May 19-25, 2001. Boating safety improved in the United States throughout the 1990s. Despite a 15% increase in boats registered, the boating fatality rate declined 32% from 1990 to 1999. However, boating-related deaths continue to occur. In 1999, 734 persons died in boating incidents. Boaters routinely should adopt safety practices.
All boaters should wear personal flotation devices (PFDs). Capsizing and falling overboard account for more than half of all recreational boating deaths each year (1 ). Although all states and territories (except Guam, Hawaii, and Idaho) have regulations on wearing life jackets, most affect only children aged <12 years.
Boaters should avoid alcoholic beverages while boating. Alcohol use affects judgment, vision, balance, and coordination. Approximately one third of all deaths caused by a collision involved alcohol use.
Boaters should be aware of the risk for carbon monoxide (CO) poisoning. Potential sources of CO poisoning include using air conditioning powered by an onboard motor generator, operating a gasoline powered engine while docked and/or rafted with other boats operating engines, or being underway with improper cabin ventilation. To avoid CO poisoning, boaters should have sufficient ventilation, properly install and maintain equipment, and use CO detectors.
Boaters should be aware of potential hazards and the regulations of operating a boat. Boating education courses teach the regulatory and statutory rules for safely operating and navigating recreational boats. The U.S. Coast Guard Auxiliary and U.S. Power Squadron offer the Vessel Safety Check (VSC) program to promote boating safety. Volunteers check safety equipment and provide information about equipment purpose, safety procedures, and applicable regulations.
Additional

# MMWR May 25, 2001
Notice to Readers -Continued

# Notice to Readers

# Responding to Fecal Accidents in Disinfected Swimming Venues
These recommendations are solely for management of fecal accidents in disinfected recreational water venues. The recommendations do not address use of other nonchlorine disinfectants because there is limited pathogen inactivation data for many of these compounds. Because improper handling of chlorinated disinfectants could cause injury, appropriate occupational safety and health requirements should be followed.
A. Formed stool (solid, nonliquid)
1. Direct everyone to leave all pools into which water containing the feces is circulated. Do not allow anyone to enter the contaminated pool(s) until all decontamination procedures are completed.
2. Remove as much of the fecal material as possible using a net or scoop and dispose of it in a sanitary manner. Clean and disinfect the net or scoop (e.g., after cleaning, leave the net or scoop immersed in the pool during disinfection). Vacuuming stool from the pool is not recommended*.
3. Raise the free available chlorine concentration to 2 mg/L, pH 7.2-7.5, if it is <2.0 mg/L. Ensure this concentration is found throughout all co-circulating pools by sampling at least three widely spaced locations away from return water outlets. This free available chlorine concentration was selected to keep the pool closure time to approximately 30 minutes. Other concentrations or closure times can be used as long as the CT inactivation value  is kept constant (Table 1).
4. Maintain the free available chlorine concentration at 2.0 mg/L, pH 7.2-7.5, for at least 25 minutes before reopening the pool. State or local regulators may require higher free available chlorine levels in the presence of chlorine stabilizers such as chlorinated isocyanurates  . Ensure that the filtration system is operating while the pool reaches and maintains the proper free available chlorine concentration during the disinfection process.
5. Establish a fecal accident log. Document each fecal accident by recording date and time of the event, formed stool or diarrhea, free available chlorine concentration at the time or observation of the event and before opening the pool, the pH, the procedures followed to respond to the fecal accident (including the process used to increase free chlorine residual if necessary), and the contact time.

# B. Diarrhea (liquid stool)
1. See A1.
2. See A2.
3. Raise the free available chlorine concentration to 20 mg/L  and maintain the pH between 7.2 and 7.5. Ensure this concentration is found throughout all co-circulating pools by sampling at least three widely spaced locations away from return water outlets. This chlorine and pH level should be sufficient to inactivate Cryptosporidium and should be maintained for at least 8 hours, equivalent to a CT inactivation value of 9600. A higher or lower free available chlorine level/inactivation time can be used as long as a CT inactivation value equaling 9600 is maintained for Cryptosporidium inactivation. State or local regulators may require higher free available chlorine levels in the presence of chlorine stabilizers such as chlorinated isocyanurates. If necessary, consult an aquatics professional to determine and identify the feasibility, practical methods, and safety considerations before attempting the hyperchlorination of any pool.
4. Ensure that the filtration system is operating while the pool reaches and maintains the proper free available chlorine concentration during disinfection.
5. Backwash the filter thoroughly after reaching the CT value. Be sure the effluent is discharged directly to waste and in accordance with state or local regulations. Do not return the backwash through the filter. Where appropriate, replace the filter media.
6. Swimmers may be allowed into the pool after the required CT value has been achieved and the free available chlorine level has been returned to the normal operating range allowed - No uniform recommendations for disinfection of vacuum systems are available. However, if a vacuum system is accidentally used, the waste should be discharged directly to a sewer or other approved waste disposal system and not through the filtration system. The dilution effect of the pool water going through the hose may reduce the risk for high-level contamination of the vacuum system.  CT refers to concentration (C) of free available chlorine in mg/L or ppm multiplied by time (T) in minutes. If pool operators want to use a different chlorine concentration or inactivation time, they need to ensure that CT values always remain the same. For example, if an operator finds a formed fecal accident in the pool and his pool has a free available chlorine reading of 3 mg/L and a pH of 7.5, to determine how long the pool should be closed to swimmers, locate 3 mg/L in the left column of the table and then move right and read the pool closure time. The pool should be closed for 19 minutes. Example 2: The CT inactivation value for Cryptosporidium is 9600, which equals (20 mg/L)(480 minutes) (i.e., 8 hours). After a diarrheal accident in the pool, an operator determines she can only maintain 15 mg/L. How long would hyperchlorination take? Answer: 9600=CT=;T=9600/15=640 minutes=10.7 hours.  The impact of chlorine stabilizers (e.g., chlorinated isocyanurates) on pathogen inactivation and disinfectant measurement is unclear and requires further investigation. State or local regulations on chlorinated isocyanurates use should be consulted.  Many conventional test kits cannot measure free available chlorine levels this high. Use chlorine test strips that can measure free available chlorine in a range that includes 20mg/L (such as those used in the food industry) or make dilutions for use in a standard DPD (N, N-diethyl-p-phenylenediamine) test kit using chlorine-free water. May 25, 2001
Notice to Readers -Continued

# Notice to Readers

# Deferral of Routine Booster Doses of Tetanus and Diphtheria Toxoids for Adolescents and Adults
A shortage of tetanus and diphtheria toxoids (Td) and tetanus toxoid (TT) in the United States has resulted because one of two manufacturers discontinued production of tetanus toxoid-containing products (1 ). Aventis Pasteur (Swiftwater, Pennsylvania) is the only major manufacturer of tetanus and Td in the United States. In response to the shortage, Aventis Pasteur has increased production of Td to meet national needs; however, because 11 months are required for vaccine production, the shortage is expected to last for the remainder of 2001.
To assure vaccine availability for priority indications (2 ), all routine Td boosters in adolescents and adults should be delayed until 2002. Td use should follow existing recommendations for all other indications, which include 1) persons traveling to a country where the risk for diphtheria is high*; 2) persons requiring tetanus vaccination for prophylaxis in wound management; 3) persons who have received <3 doses of any vaccine containing Td; and 4) pregnant women who have not been vaccinated with Td during the preceding 10 years.
CDC recommends that health-care providers, including clinic personnel, record the names of patients whose booster dose is delayed during the shortage. When Td supplies are restored, these patients should be notified to return to their health-care provider for vaccination. According to Aventis Pasteur, sufficient vaccine will be available in early 2002 to supply the national demand.
Health-care providers using Td for wound management should follow recommendations from the Advisory Committee on Immunization Practices for wound management (3 ). All wound patients should receive Td if they have received 3 doses of TT-containing vaccine and severe or contaminated wounds, Td should be given only if >5 years have passed since the last dose of tetanuscontaining vaccine. For clean and minor wounds, Td should be given only if the patient has not received a tetanus-containing vaccine during the preceding 10 years. Healthcare providers should inquire from patients presenting for wound management about the timing of their last tetanus-containing vaccine to avoid unnecessary vaccination.
Pediatric formulations of diphtheria and tetanus toxoids (DT) and diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) should not be used for persons aged >7 years. Although TT might be considered a substitute for Td in wound management      Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks.  Total includes unknown ages.

# Contributors to the Production of the MMWR (Weekly)
Weekly
when Td is not available, TT is not available for national distribution. Existing stocks of TT are extremely limited and are mainly reserved for production of tetanus immune globulin and other special circumstances. Health-care providers and institutions requiring Td for priority indications should contact Aventis Pasteur, telephone (800) 822-2463 or (800) VACCINE. Institutions should place orders for their anticipated needs for priority indications only. Limiting quantities of vaccine in each order is necessary to assure the widest possible distribution of available vaccine. For emergency situations (e.g., natural disasters) requiring increased use of Td, Aventis Pasteur can provide vaccine within 24 hours.

# The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of charge in electronic format and on a paid subscription basis for paper copy.
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Data in the weekly MMWR are provisional, based on weekly reports to CDC by state health departments. The reporting week concludes at close of business on Friday; compiled data on a national basis are officially released to the public on the following Friday. Address inquiries about the MMWR Series, including material to be considered for publication, to: Editor, MMWR Series, Mailstop C-08, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333; telephone (888) 232-3228.
All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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