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hot tubs, jacuzzi, spa baths

We need to explain to friends why our grandsons (11 and 14) are not allowed to go into hot tubs, jacuzzis, spa baths etc.

Please could you recommend research documents (if any) or any written material to help us put this danger to our grandsons over clearly to anyone who may have care for them. Thank you - jennifer mcneil
Dear questioner,
I answered a similar question lately, which exactly answers your question, so let me cite my own answer again:

I found the following 2 publications on the topic as latest:
Rosenfeld M et al. in J Cyst Fibros. 2012 Sep;11(5):446-53. “Risk factors for age at initial Pseudomonas acquisition in the cystic fibrosis epic observational cohort.”

Lutz JK1, Lee J. in Int J Environ Res Public Health. 2011 Feb;8(2):554-64. “Prevalence and antimicrobial-resistance of Pseudomonas aeruginosa in swimming pools and hot tubs.”

The colonization of the airways of CF patients with Pseudmonas aeruginosa (PA) has to be avoided as long as possible, as it is associated with decline in lung function and increased mortality. As Pseudomonas aeruginosa is a humid germ, it can be found in humid environmental conditions, especially in stagnant water with increased water temperature. Therefore hot tubs and swimming pools are a potential reservoir for Pseudomonas aeruginsoa.
A study from Switzerland in 2005 showed that the incidence of PA in public swimming pools was very low (3-7%) and therefore they did not support recommendations to avoid public swimming pools. A study from Northern Ireland in 2002 showed high incidences of PA in public swimming pools (38%) and private Jacuzzis (whirlpools) (72%). The latest study from Lutz et al. 2011 in the USA had 21% of samples from hot tubs and indoor swimming pools positive for PA and 96% of those PA positive samples had a multidrug resistant Pseudmonas.

The EPIC observational study (Rosenfeld et al., J Cyst Fibros 11:446-453, 2012) investigated risk factors for age at initial Pseudomonas acquisition in CF children. 889 CF-children under the age of 12 were included in this study and i.a. data was collected on the genotype and on certain leisure behaviors via questionnaire. It was statistically calculated if those factors could be a risk factor for an early acquisition of P.a.
It came out that the genotype had the greatest influence on the age of first acquisition of P.a.: patients with only minimal residual CFTR-function (two mutations of class I-III) had a median age of 2.9 years at first acquisition of P.a. whilst patients with remaining residual function of CFTR (at least one mutation of class IV-V) had a median age of 10.3 years. None of the evaluated factors, like e.g. usage of a swimming-pool, of a Jacuzzi or participation at social events with other CF-patients came out to be statistically a risk factor for the early acquisition of P.a..
However, experts judge these data differently: some experts are on the basis of the EPIC-study of the opinion that one should not restrict the leisure behavior too much as this study had shown that especially the underlying genotype of the patient is influencing the age at first acquisition of P.a., not however certain behaviors. Other experts contradict, that it had already been known for a long time that the genotype is the most important factor influencing age of first acquisition of P.a. However it would be clear that patients with a “high-risk genotype” would get infected with P.a. if they are exposed to P.a. in great amounts, which remain to be proved by further studies. As a consequence one could indeed delay the age of first acquisition of P.a. via a careful behavior with P.a. exposition as low as possible. Furthermore, the data of this study is methodically not so obvious that one could give concrete advice.
In summary, Pseudomonas can be found in hot tubs and indoor swimming pools, alarming is the rate of multidrug resistant species. Hot tubs are regarded as high-risk reservoirs, due to the small amount of water that is changed and the increased temperatures, as well as increased aerosol formation. Therefore, most experts recommend to avoid the use of hot tubs and Jacuzzis for CF patients. Well maintained and sufficiently chlorinated public swimming pools are regarded to have a much lower risk and most CF centers do not recommend their CF patients against the visit of those public pools. Water quality maintenance data with investigation of water germ load can often be provided by the operator of a pubic pool.
Therefore, the data remains fragmentary and recommendations try generally to find a compromise between the actual risk / risk-taking and the loss of quality of life.

Best regards,
Dr. Daniela d’Alquen (coordinator of the Central English Archive of ECORN-CF)
The answer is edited by: Prof Judy Bradley