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By Kelli M. Donley
Piped tubs in healthcare centers may be responsible for a myriad of nosocomial infections
Ancient Roman architects were known for their grandiose adaptations of outsiders' ideas. The great bath in Mohenjo-Daro, created in modern day Pakistan in 2500 BC, was no exception. Roman baths, which included exercise areas, masseurs, barbers, shops, restaurants, and libraries, became overwhelming popular places to conduct business and relax in the 2nd century BC.1
Today, baths are private, but still a common method of relaxation. They have become a billion-dollar industry. Hot tubs are provided in most fitness centers and resorts; whirlpool baths are found in hotels, homes, and healthcare centers. There is no wonder why people are drawn to warm water--the heat opens pores, relieves aches and pains, and provides a sense of comfort for those looking for a temporary escape.
However, few people realize when they fill a whirlpool bath, sit down for a soak, and lean back to breathe in the warm air, they are exposing themselves to a variety of potentially fatal bacteria and fungi. While resting in circling warm water that caresses their skin, they breathe in deeply, allowing legionella spores to reach deeply into their lungs. They stretch slowly, unwittingly allowing fecal matter, skin, and other debris left behind from the previous bather to envelope them slowly as they dip their head under the water.
Those who have made this discovery are now in litigation with three of the US's largest whirlpool manufacturers. Lawsuits are currently pending against Jacuzzi, Inc., Kohler Co., and Lasco Bathware, Inc. because consumer complaints went unheard about "yellowish sludge," "greenish-black gunk," and "black, flimy debris," coming from piping of their tubs.2
Paralegal Sylvia Bray said her firm has been receiving complaints for years concerning piped whirlpool baths. Bray works with Malesovas & Martin, a Waco, Texas law firm that has been pursuing the case since 1999.
"They (the piped tubs in question) harbor bacteria, soap debris, and scum in the piping systems back behind the jets. Then whenever the tubs are turned on and the jets are activated all of that is sloughed off...You can't (always) see it, but it circulates back into the user's water," she said.
The problem is found within the design of many tubs. Bathwater does not completely drain from the pipes. Instead, it remains in the damp and dark environment--the perfect breeding ground for bacteria--until the next time someone uses the bath. This water often includes soap film, hair, dead skin, body oil, dirt, and feces.5 These pathogens then come rushing out of the pipes, into the air and the "clean" bathwater. The person taking the bath is subject to inhaling and ingesting bacteria, along with immersing themselves in a variety of pathogens that can infect open wounds.
Those included in the suit have reported illness.
"We have some people who are ill. We have records of some people having skin rashes, respiratory, urinary tract, and Staph infections, but we don't know how many records are actually out there because the tub companies destroyed them," Bray said.
The whirlpool manufacturers in question disagree. Fred Adams, vice president of marketing for Anaheim, Calif.-based Lasco Bathware said his company is confident the suit is a mistake. Lasco is the only company in the suit that has proceeded to the rank of class-action law suit.
"Lasco is a defendant in this Texas civil-action where the plantiffs allege they have been denied pleasurable bathing experiences and Lasco denies that this is so. In a pretrial proceeding, the trial court in that action has certified a class of some Texas whirlpool tub owners, which decision is currently on appeal," he said. "We believe the court certification decision to be both mistaken and contrary to law and Lasco fully expects it will be reversed on appeal. In any event, if there is a trial, we are confident that the facts will show that the plantiffs' allegations are wholly without merit."
A representative from Kohler, Inc., who spoke under conditions of anonymity said his company doubts the validity of the lawsuit.
"Kohler has been making whirlpools for nearly 30 years, and it has never been shown that one of its whirlpools has made someone sick. That has never been demonstrated," he said.
When pressed for information concerning Kohler's records of consumer complaints concerning illness related to whirlpool baths, the representative said he was unaware of any monitoring system in place.
"We have some records... and there are no records of Kohler whirlpool contributing to somebody's illness," he said.
Jacuzzi, Inc., officials did not respond to interview requests.
Rita B. Moyes, PhD, with the Department of Biology at Texas A&M University, decided to research the water quality of 43 whirlpool baths while writing, "Microbial Loads in Whirlpool Bathtubs: An Emerging Health Risk." She found 100% of the samples, taken from both private and public tubs, contained microbial growth; 95% of the water sampled additionally contained enteric organisms; 81% had fungi; 56% had Pseudomonas sp.,; 36% had Legionella sp.,; and 34% had Staphlococcus aureus.
In her report, she writes, "Stagnant, organic-containing bath water trapped inside a system already rich in bioflim provides an ideal environment for bacteria to flourish."3
The pathogens found during the random sampling are responsible for: septicemia, urinary tract infections, intestinal infections, infections of the respiratory tract, burn wounds, ears and eyes, bacteremia, endocarditis, gastroenterisits, Legionnaire's disease, Pontiac fever, impetigo, folliculitis, furuncles, carbuncles, scalded skin syndrome, toxic shock syndrome, food poisoning, pneumonia, empyema, osteomyelitis, and septic arthritis.3
"If you think about taking a bath in a whirlpool tub, you should realize that warm water is going to open up your pores and the whirlpool action is going to create an aerosol that can then enter your lungs. Lung infections (Legionnaire's disease), urinary tract infections, and skin infections have already been documented in hot tubs, which have basically the same design except they are filtered and chemically treated. The problem with a bathtub is, you (generally) only have one or two users, and if you get an infection the doctor will just treat it and not try to find the source--opposed to an outbreak associated with a hot tub on a cruise ship for instance," she said.
The first infection traced back to a whirlpool bath was noted in literature in 1972.3 Yet, this source of infection continues to be a public health threat today. There have been multiple disease outbreaks reported concerning hot tubs and whirlpool baths in recent years. Bacteria are pushed into the air via whirlpool jets and can be inhaled by both bathers and passersby.
Bacteria and pathogens found in the water can also cause axiomatic problems. Fecal matter is often found in bath water. In piped whirlpool baths, this dirty water is stored until the next use.
"A number of fecal bacteria were isolated from the tub--Escherichia coli, and Proteus sp. for instance. Staphylococcus aureus was isolated and is responsible for skin infections. Legionella sp. was also found and causes Legionnaire's disease. Pseudomonas aeruginosa--responsible for skin, eye, ear, and lung infections was found. Fungi were also isolated and can be responsible for lung infections," Moyes said.
Jacuzzi has reportedly sold more than 2 million whirlpool baths, 600,000 of them in the past 4 years, to homebuilders, healthcare centers, and hotels.5 Any piped tub should be scrutinized and examined by infection control practitioners as a source of potential hospital-borne infections. Perhaps hospital outbreaks caused by waterborne illness go unnoticed? Swabbing the tubing of a piped tub for pathogen testing can ease an administrator's worries, or shed light on a serious health risk.
Imagine the frustration of a healthcare team who works ardently at helping a patient heal, only to watch the person become violently ill with a pathogen obtained from the hospital's whirlpool bath. This situation is not uncommon, yet it can be prevented.
Janis Kennedy, RN, CIC, and infection control nurse at St. Boniface General Hospital, in Winnipeg, Manitoba said her hospital is in the process of installing several new pipeless tubs. St. Boniface has 13 bathtubs, including 5 piped whirlpool tubs.
"The whirlpool baths are used for patient bathing--mostly on the extended care wards--although there are some whirlpools on surgical wards. Surgical patients with incisions do not use the tubs," she said. "We have cultured pseudomonas from our whirlpool tubs, however we have not had outbreaks associated with this.
"We have replaced most of the whirlpool tubs with Arjo hydrosound tubs. The hydrosound tubs have a solid tub shell surface and ultrasound waves provide a gentle wave motion. There are no motors or jets."
While piped whirlpool manufacturers recommend several different methods of cleaning their systems, mild detergents cannot eliminate skin flora and other pollutants from bath water.
"First off, people need to realize the danger exists and be aware that if they are suffering recurring infections the source could be their tub. Also, everyone needs to adhere to a rigid cleaning regime," Moyes said. "If I owned a tub I would clean it after each bath! Certainly the one-fourth cup of bleach or detergent per 50-gallon tub that the manufacturers recommend is not enough.
"Also, if building, research what type of tub you are going to install. There are new pipeless tubs on the market and tubs in which the pipes can be closed off and cleaned without having to fill the entire tub with water. Beware, just because the manufacturer says their pipes don't harbor bacteria doesn't mean that its so," she said.
Sanijet, based in Coppell, Texas, is the sole manufacturer of a pipeless whirlpool bath. The patented system uses individual jets that can be removed by hand. These jets easily can be removed and cleaned within a few minutes. The system has received independent verification from the National Sanitation Foundation that it can be completely cleaned and disinfected.
Philip Klement, vice president of sales and marketing at Sanijet, said while the company is fighting an uphill battle against the more recognized brands of whirlpool baths, their innovative technology helps them stand out.
"We are the only maker of a pipeless whirlpool bath. We are the only one out there spreading the message. Sometimes that is viewed with a lot of scrutiny because we stand to profit or gain from the demise of the piped whirlpool category," he said.
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