Proper risk management includes daily inspections, regular cleaning, usage policies and water tests
Hot tub operators are reporting an increasing number of “hot tub rash” claims from people using their equipment. Although the rash is not a serious threat to health, such claims can be prevented or reduced by adhering to a regular schedule of equipment cleaning and maintenance.
Hot tub rash is the common name for pseudomonas folliculitis, a skin inflammation caused by the very common bacterium pseudomonas aeruginosa, which is present on the skin of about 15 percent of the general population. The infection may be spread by exposure to contaminated water in hot tubs and surrounding areas. People who use a hot tub together, such as families or groups of friends, often become infected simultaneously.
The rash, characterized by red, itchy bumps resembling insect bites, usually occurs two to three days after exposure to contaminated water, though symptoms may develop anytime from six hours after bathing to a week later. The rash typically appears on the arms, legs and trunk; it may be more severe under a swimsuit, where fabric holds contaminated water against the skin. Showering or bathing after exposure has not been shown to prevent, delay or lessen infection. Most cases usually resolve without medical treatment within one to two weeks, though persistent cases may require a course of antibiotics.
Most cases of contaminated hot tubs occur when bathers who carry the pseudomonas aeruginosa bacteria on their skin introduce the bacteria to the water and the equipment. The warm, moist conditions in and around the hot tub are ideal for the growth and spread of the bacteria, which feeds on the organic materials typically present in a hot tub (body oils and fluids, cosmetics, perspiration, etc.).
Dangerous concentrations of bacteria can develop quickly. When many people use the tub simultaneously or in succession, the higher concentrations of organic material may overwhelm the tub’s disinfectant, allowing the bacteria to multiply.
When sufficient disinfectant levels are not maintained (even for a few hours) or if the tub and its equipment are not kept clean, pseudomonas will quickly establish colonies in the water; on tub surfaces, ladders and covers, in the filters and even within the plumbing. Once established, the bacteria colonies generate a biofilm, a slimy layer that protects them from the disinfectant and from removal efforts.
Establishing a Risk Reduction Program
Hot tub operators can prevent hot tub rash and associated claims simply by keeping the tub very clean and continuously disinfected. Agents working with hot tub operators should stress the importance of developing procedures for maintenance, inspection, monitoring and incident response, as well as maintaining records for all inspections and tests. Staff should be adequately trained and sufficient staff should be scheduled during busy periods. Before renting the hot tub for parties or other events, operators should check with local health officials to determine what is permitted for their facility.
A schedule should be established for testing the water temperature, pH level and disinfectant concentration. This schedule may vary depending on use. On days of heavy use, frequent testing and treatment will be required, perhaps on an hourly basis. Operators should keep records of all tests and measurements.
In addition, operators should maintain the water temperature, pH level and disinfectant concentration recommended by manufacturers and public health officials at all times, whether use is light or heavy, and even on days no one is using the tub. If the disinfectant is not maintained at a constant optimal level, bacteria will quickly form colonies and develop a biofilm that will allow the bacteria to survive despite the restoration of normal disinfection levels at the next use or business day.
Hot tub operators should treat the water with a biocidal “shock” product on a regular basis. Before applying the shock product, the tub should be scrubbed to break up any biofilm; this will make the disinfectant more effective.
It is also important to establish an inspection and maintenance program for all components of the hot tub system. All equipment requires regular testing to ensure that it is in proper working order. Operators should inspect the tub every day, looking for slime, mold or mildew, especially around the water line. The water should be clear and sparkling and smell only of disinfectant. And the cover should not have unpleasant odors, slime, mold, mildew or discoloration.
Hot tubs must be kept very clean. Operators should scrub away all slime, dirt, etc., and drain the water on a regular basis. Scrub the drained tub with a non-foaming, pH-neutral cleanser. Clean the filters and hardware, and replace the filters at least once each year, depending on usage. The tub should be kept covered when not in use. If the cover is in good condition and is not contaminated, it should be cleaned inside and out with a non-foaming, pH-neutral cleanser.
A key component to prevent contamination is to establish and enforce usage policies. Operators should post information about the “permitted number of bathers” prominently, and enforce it. The facility should prohibit hot tub use by children younger than five; any person using a diaper, incontinence product or external feminine sanitary product; or any person with open wounds or rashes. All bathers should be required to shower prior to entering the hot tub.
If the hot tub becomes contaminated, the operator should prevent people from using the tub and take immediate steps to eradicate the infection. Signs of contamination include disinfectant levels less than 1 ppm for six or more hours; rash on bathers or employees; complaints from bathers; presence of slime on the tub, fixtures, or cover; unpleasant smells from the water or cover; or cloudy or foamy water.
Prior to beginning decontamination, the operator or employees should wear appropriate personal protective equipment.
The tub should be drained, disinfected and a new filter installed. The tub surfaces and fixtures should be scrubbed with a bleach solution to remove all slime. The tub is then rinsed, drained, refilled and a shock biocide treatment administered. The jets should be turned on and the water circulated for two to three hours. The operator should drain, rinse and refill the tub. After rebalancing the water, the operator should shock the water again. The facility should not allow any bathing until the disinfectant level drops below 4.0 ppm. To prevent recontamination, the operator should sanitize the shower, floors, drains, plumbing fixtures, chairs, door handles and other nearby surfaces. If the tub cover is contaminated, the operator should discard it.
For detailed information on preventing pseudomonas contamination in hot tubs, request the Sequoia Risk Management Guide SRMG-011, “Understanding and Preventing Hot Tub Rash.”
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