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A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Environmental Health".

Deadline for manuscript submissions: closed (31 October 2018) | Viewed by 70171

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Prof. Dr. Erica Leoni

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Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna 40126, Italy
Interests: public health; environmental microbiology; infection control; epidemiology; health promotion

Special Issue Information

Dear Colleagues,

Swimming and other water-based exercises are excellent ways to practice physical activity and to gain health and social benefits. However, recreational water use may expose people to different health risks due to the exposure to chemicals or infectious pathogens. The safety of recreational aquatic environments is affected by numerous variables such as water quality, health conditions of users, the correct functioning of the technological systems used for water treatment.

This Special Issue aims to provide new information about health risks in treated recreational waters (e.g., pools and spas) or untreated waters (e.g., surface water, natural pools, and thermal springs), together with the need to update prevention strategies. We encourage submission of papers concerning the monitoring and control of the chemical and infectious risks associated with recreational waters, the surveillance of infectious diseases in swimming pools and spas, and the study of outbreaks caused by traditional or emerging microorganisms. Papers focused on the adverse health effects due to disinfection by-products (DBPs) in swimming pools are also welcome. Of particular concern is the development of risk control approaches, including the application of effective innovative technologies, the promotion of healthy behaviors, and the design of appropriate polices for surveillance and controls.

Prof. Dr. Erica Leoni
Guest Editor

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Keywords

recreational water
swimming pools and spas
thermal springs
infectious risk
disinfection by-products
epidemiological surveillance
health protection

Published Papers (12 papers)

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Research

Jump to: Review

18 pages, 1617 KiB

Open AccessArticle

Occurrence of Antibiotic-Resistant Bacteria in Therapy Pools and Surrounding Surfaces

by Daniela E. Koeck, Stefanie Huber, Nadera Hanifi, Manfred Köster, Martina B. Schierling and Christiane Höller

Int. J. Environ. Res. Public Health 2018, 15(12), 2666; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15122666 - 27 Nov 2018

Cited by 5 | Viewed by 3487

Abstract

The number of patients colonized with antibiotic-resistant bacteria is increasing in health care facilities. Because transmission of antibiotic-resistant bacteria is feared, there exist reports that the affected patients are frequently excluded from hydrotherapy, which is a non-invasive and beneficial treatment used for patients with different diseases. Data from the literature suggest that deficient water disinfection measures exist, which are not always sufficient to kill all released bacteria. If the pool water is not disinfected properly, it may also infect the bathers. Immunocompromised patients are particularly susceptible to be infected with (antibiotic-resistant) bacteria. In order to determine the distribution of antibiotic-resistant bacteria in the pool water treatment system and the pool environment and to estimate the associated transmission risk we analyzed samples from eleven health care facilities. Antibiotic-resistant bacteria were found in the water and surface samples collected. One hundred and two antibiotic-resistant isolates from water samples and 307 isolates from surrounding surfaces were obtained, respectively. The majority of the isolates belonged to non-fermenting Gram-negative rods, like Pseudomonas spp. Some isolates were resistant to a wide range of the tested antibiotics. The results indicate a relation between the number of isolates in water samples and the number of patients using the pools in combination with deficiencies in water treatment. In the pool environment the highest number of isolates was obtained from barefoot areas and floor cleaning equipment. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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13 pages, 1109 KiB

Open AccessArticle

Salmonella enterica Serovar Typhimurium and Escherichia coli Survival in Estuarine Bank Sediments

by Mahbubul H. Siddiqee, Rebekah Henry, Rebecca Coulthard, Christelle Schang, Richard Williamson, Rhys Coleman, Graham Rooney, Ana Deletic and David McCarthy

Int. J. Environ. Res. Public Health 2018, 15(11), 2597; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15112597 - 21 Nov 2018

Cited by 3 | Viewed by 3095

Abstract

Estuarine bank sediments have the potential to support the survival and growth of fecal indicator organisms, including Escherichia coli. However, survival of fecal pathogens in estuarine sediments is not well researched and therefore remains a significant knowledge gap regarding public health risks in estuaries. In this study, simultaneous survival of Escherichia coli and a fecal pathogen, Salmonella enterica serovar Typhimurium, was studied for 21 days in estuarine bank sediment microcosms. Observed growth patterns for both organisms were comparable under four simulated scenarios; for continuous-desiccation, extended-desiccation, periodic-inundation, and continuous-inundation systems, logarithmic decay coefficients were 1.54/day, 1.51/day, 0.14/day, and 0.20/day, respectively, for E. coli, and 1.72/day, 1.64/day, 0.21/day, and 0.24/day for S. Typhimurium. Re-wetting of continuous-desiccated systems resulted in potential re-growth, suggesting survival under moisture-limited conditions. Key findings from this study include: (i) Bank sediments can potentially support human pathogens (S. Typhimurium), (ii) inundation levels influence the survival of fecal bacteria in estuarine bank sediments, and (iii) comparable survival rates of S. Typhimurium and E. coli implies the latter could be a reliable fecal indicator in urban estuaries. The results from this study will help select suitable monitoring and management strategies for safer recreational activities in urban estuaries. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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9 pages, 1209 KiB

Open AccessArticle

Norovirus Outbreak Associated with Swimming in a Recreational Lake Not Influenced by External Human Fecal Sources in The Netherlands, August 2012

by Franciska M. Schets, Harold H. J. L. Van den Berg, Harry Vennema, Manon T. M. Pelgrim, Cees Collé, Saskia A. Rutjes and Willemijn J. Lodder

Int. J. Environ. Res. Public Health 2018, 15(11), 2550; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15112550 - 14 Nov 2018

Cited by 10 | Viewed by 3194

Abstract

Swimming in fecally contaminated recreational water may lead to gastrointestinal illness. A recreational water-associated outbreak of norovirus (NoV) infections affecting at least 100 people in The Netherlands occurred in August 2012. Questionnaire responses from patients indicated swimming in recreational lake Zeumeren as the most likely cause of illness. Most patients visited the lake during the weekend of 18–19 August, during which the weather was exceptionally warm (maximum temperatures 32–33 °C), and visitor numbers elevated. Patients, mostly children, became ill with gastroenteritis 1–6 days (median 2 days) after exposure. Four stool samples from patients were NoV GI positive. Subsurface sandy soil from one of the beaches where most patients swam was NoV GI positive; the water sample was negative. The epidemiological curve and the timeline of investigation based on reported symptoms demonstrate the difficulty in discovering the source in recreational water outbreaks. A NoV outbreak in a recreational lake that is not subjected to external fecal contamination sources shows the need for active communication about human shedding of viruses during and after diarrheal episodes and the advice to refrain from swimming, even a few weeks after the symptoms have resolved. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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6 pages, 638 KiB

Open AccessArticle

Validation of Questionnaire Methods to Quantify Recreational Water Ingestion

by Laura M. Suppes, Kacey C. Ernst, Leif Abrell and Kelly A. Reynolds

Int. J. Environ. Res. Public Health 2018, 15(11), 2435; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15112435 - 01 Nov 2018

Cited by 1 | Viewed by 2849

Abstract

Swimming pool water ingestion volumes are necessary for assessing infection risk from swimming. Pool water ingestion volumes can be estimated by questionnaire or measuring a chemical tracer in swimmer urine. Questionnaires are often preferred to the chemical tracer method because surveys are less time consuming, but no research exists validating questionnaires accurately quantify pool water ingestion volumes. The objective of this study was to explore if questionnaires are a reliable tool for collecting pool water ingestion volumes. A questionnaire was issued at four pool sites in Tucson, Arizona to 46 swimmers who also submitted a urine sample for analyzing cyanuric acid, a chemical tracer. Perceived ingestion volumes reported on the questionnaire were compared with pool water ingestion volumes, quantified by analyzing cyanuric acid in swimmer urine. Swimmers were asked if they swallowed (1) no water or only a few drops, (2) one to two mouthfuls, (3) three to five mouthfuls, or (4) six to eight mouthfuls. One mouthful is the equivalent of 27 mL of water. The majority (81%) of swimmers ingested <27 mL of pool water but reported ingesting >27 mL (“one mouthful”) on the questionnaire. More than half (52%) of swimmers overestimated their ingestion volume. These findings suggest swimmers are over-estimating pool water ingestion because they perceive one mouthful is <27 mL. The questionnaire did not reliably collect pool water ingestion volumes and should be improved for future exposure assessment studies. Images of the ingestion volume categories should be included on the questionnaire to help swimmers visualize the response options. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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19 pages, 854 KiB

Open AccessFeature PaperArticle

Legionellosis Associated with Recreational Waters: A Systematic Review of Cases and Outbreaks in Swimming Pools, Spa Pools, and Similar Environments

by Erica Leoni, Federica Catalani, Sofia Marini and Laura Dallolio

Int. J. Environ. Res. Public Health 2018, 15(8), 1612; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15081612 - 30 Jul 2018

Cited by 42 | Viewed by 5346

Abstract

Legionella spp. is widespread in many natural and artificial water systems, such as hot water distribution networks, cooling towers, and spas. A particular risk factor has been identified in the use of whirlpools and hot tubs in spa facilities and public baths. However, there has been no systematic synthesis of the published literature reporting legionellosis cases or outbreaks related to swimming/spa pools or similar environments used for recreational purposes (hot springs, hot tubs, whirlpools, natural spas). This study presents the results of a systematic review of the literature on cases and outbreaks associated with these environments. Data were extracted from 47 articles, including 42 events (17 sporadic cases and 25 outbreaks) and 1079 cases, 57.5% of which were diagnosed as Pontiac fever, without any deaths, and 42.5% were of Legionnaires’ disease, with a fatality rate of 6.3%. The results are presented in relation to the distribution of Legionella species involved in the events, clinical manifestations and diagnosis, predisposing conditions in the patients, favourable environmental factors, and quality of the epidemiological investigation, as well as in relation to the different types of recreational water sources involved. Based on the epidemiological and microbiological criteria, the strength of evidence linking a case/outbreak of legionellosis with a recreational water system was classified as strong, probable, and possible; in more than half of the events the resulting association was strong. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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12 pages, 1459 KiB

Open AccessArticle

Assessment of Microbiological Safety of Water in Public Swimming Pools in Guangzhou, China

by Xiaohong Wei, Juntao Li, Shuiping Hou, Conghui Xu, Hao Zhang, Edward Robert Atwill, Xunde Li, Zhicong Yang and Shouyi Chen

Int. J. Environ. Res. Public Health 2018, 15(7), 1416; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15071416 - 05 Jul 2018

Cited by 19 | Viewed by 4302

Abstract

This study assessed microbiological safety of water from public swimming pools in Guangzhou, China. Water samples from 39 outdoor municipal swimming pools were collected from late June to early September, 2013 and subjected to detection of protozoa (Giardia and Cryptosporidium) and bacteria (Pseudomonas aeruginos, total coliforms, E. coli, E. coli O157, Shigella, and Salmonella). Cryptosporidium and Giardia were both detected in 5 (12.8%) swimming pools. Total coliforms were detected in 4 (10.3%) samples with concentrations ranging from 1.3 to 154.0 MPN/100 mL while E. coli was detected in 4 (10.3%) samples with concentrations ranging from 0.5 to 5.3 MPN/100 mL. P. aeruginosa was detected in 27 (69.2%) samples but E. coli O157, Shigella and Salmonella were not detected. Among these swimming pools, 9 (23%) met the Chinese National Standard of residual chlorine levels and 24 (62%) were tested free of residual chlorine at least once. The multi-locus sequence typing (MLST) analysis showed that all P. aeruginosa isolates belonged to new sequence types (STs) with dominant ST-1764 and ST-D distributed in different locations within the area. Some P. aeruginosa strains were resistant to medically important antibiotics. Results indicate potential public health risks due to the presence of microbiological pathogens in public swimming pools in this area. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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15 pages, 4158 KiB

Open AccessArticle

Antibiotic Sensitivity Profiling and Virulence Potential of Campylobacter jejuni Isolates from Estuarine Water in the Eastern Cape Province, South Africa

by Anthony C. Otigbu, Anna M. Clarke, Justine Fri, Emmanuel O. Akanbi and Henry A. Njom

Int. J. Environ. Res. Public Health 2018, 15(5), 925; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15050925 - 06 May 2018

Cited by 22 | Viewed by 5094

Abstract

Campylobacter jejuni (CJ) is a zoonotic microbe and a major causative organism of diarrheal infection in humans that often has its functional characteristics inactivated in stressed conditions. The current study assessed the correlation between recovered CJ and water quality parameters and the drug sensitivity patterns of the pathogen to frontline antibiotics in human and veterinary medicine. Water samples (n = 244) from rivers/estuarines were collected from April–September 2016, and physicochemical conditions were recorded on-site. CJ was isolated from the samples using standard microbiological methods and subjected to sensitivity testing to 10 antibiotics. Mean CJ counts were between 1 and 5 logs (CFU/mL). Ninety-five isolates confirmed as CJ by PCR showed varying rates of resistance. Sensitivity testing showed resistance to tetracycline (100%), azithromycin (92%), clindamycin (84.2%), clarithromycin and doxycycline (80%), ciprofloxacin (77.8%), vancomycin (70.5%), erythromycin (70%), metronidazole (36.8%) and nalidixic acid (30.5%). Virulence encoding genes were detected in the majority 80/95, 84.2%) of the confirmed isolates from cdtB; 60/95 (63.2%) from cstII; 49/95 (51.6%) from cadF; 45/95 (47.4%) from clpP; 30/95 (31.6%) from htrB, and 0/95 (0%) from csrA. A multiple resistance cmeABC active efflux pump system was present in 69/95 (72.6) isolates. The presence of CJ was positively correlated with temperature (r = 0.17), pH (r = 0.02), dissolved oxygen (r = 0.31), and turbidity (r = 0.23) but negatively correlated with salinity (r = −0.39) and conductivity (r = −0.28). The detection of multidrug resistant CJ strains from estuarine water and the differential gene expressions they possess indicates a potential hazard to humans. Moreover, the negative correlation between the presence of the pathogen and physicochemical parameters such as salinity indicates possible complementary expression of stress tolerance response mechanisms by wild-type CJ strains. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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15 pages, 554 KiB

Open AccessArticle

Legionella spp. Risk Assessment in Recreational and Garden Areas of Hotels

by Antonios Papadakis, Dimosthenis Chochlakis, Vassilios Sandalakis, Maria Keramarou, Yannis Tselentis and Anna Psaroulaki

Int. J. Environ. Res. Public Health 2018, 15(4), 598; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15040598 - 26 Mar 2018

Cited by 24 | Viewed by 11118

Abstract

Several Travel-associated Legionnaires’ disease (TALD) cases occur annually in Europe. Except from the most obvious sites (cooling towers and hot water systems), infections can also be associated with recreational, water feature, and garden areas of hotels. This argument is of great interest to better comprehend the colonization and to calculate the risk to human health of these sites. From July 2000–November 2017, the public health authorities of the Island of Crete (Greece) inspected 119 hotels associated with TALD, as reported through the European Legionnaires’ Disease Surveillance Network. Five hundred and eighteen samples were collected from decorative fountain ponds, showers near pools and spas, swimming pools, spa pools, garden sprinklers, drip irrigation systems (reclaimed water) and soil. Of those, 67 (12.93%), originating from 43 (35.83%) hotels, tested positive for Legionella (Legionella pneumophila serogroups 1, 2, 3, 6, 7, 8, 13, 14, 15 and non-pneumophila species (L. anisa, L. erythra, L. taurinensis, L. birminghamensis, L. rubrilucens). A Relative Risk (R.R.) > 1 (p < 0.0001) was calculated for chlorine concentrations of less than 0.2 mg/L (R.R.: 54.78), star classification (<4) (R.R.: 4.75) and absence of Water Safety Plan implementation (R.R.: 3.96). High risk (≥10⁴ CFU/L) was estimated for pool showers (16.42%), garden sprinklers (7.46%) and pool water (5.97%). Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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Review

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11 pages, 305 KiB

Open AccessReview

A Review and Update on Waterborne Viral Diseases Associated with Swimming Pools

by Lucia Bonadonna and Giuseppina La Rosa

Int. J. Environ. Res. Public Health 2019, 16(2), 166; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph16020166 - 09 Jan 2019

Cited by 51 | Viewed by 10433

Abstract

Infectious agents, including bacteria, viruses, protozoa, and molds, may threaten the health of swimming pool bathers. Viruses are a major cause of recreationally-associated waterborne diseases linked to pools, lakes, ponds, thermal pools/spas, rivers, and hot springs. They can make their way into waters through the accidental release of fecal matter, body fluids (saliva, mucus), or skin flakes by symptomatic or asymptomatic carriers. We present an updated overview of epidemiological data on viral outbreaks, a project motivated, among other things, by the availability of improved viral detection methodologies. Special attention is paid to outbreak investigations (source of the outbreak, pathways of transmission, chlorination/disinfection). Epidemiological studies on incidents of viral contamination of swimming pools under non-epidemic conditions are also reviewed. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

39 pages, 2486 KiB

Open AccessReview

Relationships between Microbial Indicators and Pathogens in Recreational Water Settings

by Asja Korajkic, Brian R. McMinn and Valerie J. Harwood

Int. J. Environ. Res. Public Health 2018, 15(12), 2842; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15122842 - 13 Dec 2018

Cited by 109 | Viewed by 8135

Abstract

Fecal pollution of recreational waters can cause scenic blight and pose a threat to public health, resulting in beach advisories and closures. Fecal indicator bacteria (total and fecal coliforms, Escherichia coli, and enterococci), and alternative indicators of fecal pollution (Clostridium perfringens and bacteriophages) are routinely used in the assessment of sanitary quality of recreational waters. However, fecal indicator bacteria (FIB), and alternative indicators are found in the gastrointestinal tract of humans, and many other animals and therefore are considered general indicators of fecal pollution. As such, there is room for improvement in terms of their use for informing risk assessment and remediation strategies. Microbial source tracking (MST) genetic markers are closely associated with animal hosts and are used to identify fecal pollution sources. In this review, we examine 73 papers generated over 40 years that reported the relationship between at least one indicator and one pathogen group or species. Nearly half of the reports did not include statistical analysis, while the remainder were almost equally split between those that observed statistically significant relationships and those that did not. Statistical significance was reported less frequently in marine and brackish waters compared to freshwater, and the number of statistically significant relationships was considerably higher in freshwater (p < 0.0001). Overall, significant relationships were more commonly reported between FIB and pathogenic bacteria or protozoa, compared to pathogenic viruses (p: 0.0022–0.0005), and this was more pronounced in freshwater compared to marine. Statistically significant relationships were typically noted following wet weather events and at sites known to be impacted by recent fecal pollution. Among the studies that reported frequency of detection, FIB were detected most consistently, followed by alternative indicators. MST markers and the three pathogen groups were detected least frequently. This trend was mirrored by reported concentrations for each group of organisms (FIB > alternative indicators > MST markers > pathogens). Thus, while FIB, alternative indicators, and MST markers continue to be suitable indicators of fecal pollution, their relationship with waterborne pathogens, particularly viruses, is tenuous at best and influenced by many different factors such as frequency of detection, variable shedding rates, differential fate and transport characteristics, as well as a broad range of site-specific factors such as the potential for the presence of a complex mixture of multiple sources of fecal contamination and pathogens. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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21 pages, 801 KiB

Open AccessFeature PaperReview

Exotic Tourist Destinations and Transmission of Infections by Swimming Pools and Hot Springs—A Literature Review

by Athena Mavridou, Olga Pappa, Olga Papatzitze, Chrysa Dioli, Anastasia Maria Kefala, Panagiotis Drossos and Apostolos Beloukas

Int. J. Environ. Res. Public Health 2018, 15(12), 2730; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15122730 - 03 Dec 2018

Cited by 22 | Viewed by 6585

Abstract

A growing number of people undertake international travel, and yet faster growth of such travel is expected in the tropics. Information on the hazards presented by pool and hot spring waters in tropical countries is very limited. This review aims to collate available information on pool water quality, alongside data on cases and outbreaks associated with swimming in pools in tropical regions affecting both local populations and travellers. Bacteria species commonly causing cases and outbreaks in the tropics as well as elsewhere in the world were excluded, and the review focuses on studies related to pathogens that, with the exception of Cryptosporidium, are unusual in more temperate climates. Studies concerning subtropical countries were included in the light of climate change. Diseases transmitted by vectors breeding in poorly maintained, neglected or abandoned pools were also included. 83 studies dealing with Microsporidia, Leptospira spp., Schistosomas spp., Cryptosporidium spp., Acanthamoeba spp., Naegleria spp., Clostridium trachomatis, viruses, and vectors breeding in swimming pool and hot tub waters, and fulfilling predefined criteria, have been included in our survey of the literature. In conclusion, prevention strategies for pool safety in the tropics are imperative. Public health authorities need to provide guidance to westerners travelling to exotic destinations on how to protect their health in swimming pools. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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22 pages, 3810 KiB

Open AccessFeature PaperReview

Recreational Use of Spa Thermal Waters: Criticisms and Perspectives for Innovative Treatments

by Federica Valeriani, Lory Marika Margarucci and Vincenzo Romano Spica

Int. J. Environ. Res. Public Health 2018, 15(12), 2675; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph15122675 - 28 Nov 2018

Cited by 29 | Viewed by 5816

Abstract

Natural spa springs are diffused all over the world and their use in pools is known since ancient times. This review underlines the cultural and social spa context focusing on hygiene issues, public health guidelines and emerging concerns regarding water management in wellness or recreational settings. The question of the "untouchability" of therapeutic natural waters and their incompatibility with traditional disinfection processes is addressed considering the demand for effective treatments that would respect the natural properties. Available strategies and innovative treatments are reviewed, highlighting potentials and limits for a sustainable management. Alternative approaches comprise nanotechnologies, photocatalysis systems, advanced filtration. State of the art and promising perspectives are reported considering the chemical-physical component and the biological natural complexity of the spa water microbiota. Full article

(This article belongs to the Special Issue Recreational Water Illnesses)

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