PUBLIC HEALTH BRIEFS
the reason for visits to the physician, and the type of physician visited. The variation in response by diagnostic category seems somewhat idiosyncratic. We had anticipated a lower response rate for the more "intimate" diagnoses, such as vulvovaginitis and gynecology examination, or some consistent difference in response rate by severity of the diagnosis. The data do not suggest this kind of variation, however. For example, the diagnosis of pharyngitis (acute, self-limited) and that of hypertension (chronic, potentially serious) both had low rates of response.* The variation in response rate by physician suggests that the relationship between the physician and the patient may affect the level of response. Despite the lack of a certain explanation for the variation in response, our results will help to guide us in our future polling of patients and possibly help other projects estimate the response when attempting to obtain release of records for peer review or research purposes. *It is interesting to note that whatever the reasons for differences by diagnosis, they seem to apply to both the Washtenaw patients and the patients of another smaller sample (Wayne County); the Spearman rank order correlation between the diagnostic responses of the two counties was r, = 0.68, p < .05. This suggests some consistency in the effect of the diagnosis on the likelihood of responses to the permission request. Relationships between diagnosis and physician were not explored, however.
Summary 2,163 patients of 55 physicians in one county, were sent letters asking for their written permission to have their medical records audited by the University of Michigan research team. The overall positive response rate was 64.1 per cent for one county. Differences in response rates were statistically significant among specialties, among diagnoses, and among individual physicians.
REFERENCES 1. Payne, B. C., and Lyons, T. F. Detailed Statistics and Methodologies for Studies of Personal Medical Care in Hawaii, Ann Arbor, Michigan, University Microfilms, 1972. 2. Hulka, B. S., and Cassel, J. C., The AAFP-UNC study of the organization, utilization, and assessment of primary medical care, Am. J. Public Health, 63:494-501, 1973. 3. Hare, R. L., and Barnoon, S. Medical Care Appraisal and Quality Assurance in the Office Practice of Internal Medicine, San Francisco, California, American Society of Internal Medicine, 1973.
ACKNOWLEDGMENTS This project was supported by Grant No. ROI HS 01583 from the Bureau of Health Services Research, Health Resources Administration, HEW.
Pseudomonas aeruginosa Serogroup 1 1 and Pool-Associated Skin Rash JAY A. JACOBSON, MD, A. W. HOADLEY, PHD, AND JOHN J. FARMER, III, PHD Pseudomonas aeriuginosa has been isolated from the skin of affected persons in three outbreaks of rash illness associated with motel whirlpools that occurred in the United States within the past four years.1-3 In these outbreaks, the rash developed approximately one to three days after the bathers used the pool. It appeared on the trunk and limbs and was accentuated in areas that had been covered by a bathing suit. It resolved within a week without specific treatment. Attack rates among pool users in these outbreaks ranged from 53 percent to 85 percent. The evidence implicating P. aeruginosa as the etiologic Address reprint requests to Dr. Jay A. Jacobson, Bacterial Diseases Division, Bureau of Epidemiology, Center for Disease Control, Atlanta, GA 30333. Dr. Farmer is also at CDC; Dr. Hoadley is with the Georgia Institute of Technology, Atlanta. This paper, submitted to the Journal February 23, 1976, was revised and accepted
for publication July 6, 1976. 1092
agent is circumstantial. In no outbreak did rash occur in persons who did not use the whirlpool. Numerous environmental samples including carpeting, filters, drains, and, in one investigation,2 the whirlpool water itself, have been positive for P. aeruginosa. In the outbreaks P. aeruginosa, serogroup 11, was recovered from I of 2, 2 of 2, and 4 of 4 affected bathers who were cultured. Serogroup 4 was isolated from the affected skin of the other bather cultured in the first investigation. In 2 of the 3 investigations2' 3 isolates of serogroup 11 were recovered from environmental sources, including pool water. Serogroups other than 11 were cultured from pools in adjacent motels that were unassociated with cases of skin rash. The recurrent association between rash illness and whirlpools and the repeated isolation of a single serogroup of P. aeruginosa prompted the authors to conduct a limited study of P. aeruginosa contamination of whirlpools in the Atlanta, Georgia area. AJPH November, 1976, Vol. 66, No. 11
PUBLIC HEALTH BRIEFS
Water samples were obtained from whirlpools at six health spas, a motel, and an apartment complex. Chlorine content was measured by the orthotolidine test. Pool temperatures ranged from 360 to 420 C, pH from 5.8 to 7.8, and total chlorine residual from 0 to greater than 3.0 mg per liter. Seventeen (71 per cent) of 24 samples were positive for P. aeruginosa. In the positive samples the median most probable number (MPN) of organisms was 33/100 ml, and the populations of some exceeded 2400/100 ml. Although many of the samples contained multiple serogroups, serogroup 11 was demonstrated most frequently (7/17, 41 per cent). Coliforms with a median MPN of 25/100 ml were isolated from six (25 per cent) of 24 samples. P. aeruginosa was recovered from pools with and without coliform contamination, including pools that had acceptable levels of free chlorine.
Discussion The fact that P. aeruginosa grows in swimming pools and other moist environments has been amply documented,4' 5Its ability to grow at 42° C is a well established property,5 and it has also been shown to grow in distilled water6 and in surface waters.7 Thus, it is not surprising that the species may be recovered from the water and wet surfaces of heated whirlpools. Of concern, however, are the possible consequences this may have for pool users. Whether P. aeruginosa causes the rash illness is not entirely clear. The affected bathers' skin may simply have been colonized with the organism and their rash due to another agent such as a chemical irritant. Cultures of bathers who did not develop a rash would have helped to evaluate this possibility, but, unfortunately, they were not obtained. There are, however, several bits of experimental evidence that tend to support the view that P. aeruginosa could, indeed, be the cause of these outbreaks. First, while it is not part of the skin's normal flora,8 hydration of the skin and alteration of its normal flora appear to promote the growth of Pseudomonas.9 Second, some strains of P. aeruginosa produce exotoxins that cause inflammation, edema, and hemorrhage in the skin of test animals.10 Third, in aqueous solution, P. aerluginosa breaks down human callus.9 Fourth, pseudomonads were the predominant bacteria recovered from a pustular skin rash produced experimentally in volunteers by continuous wet occlusion of selected skin sites. 11 The corresponding prevalence of P. aertiginosa, serogroup 11, among isolates from patients and whirlpools led to our hypotheses that: (1) these strains of serogroup 11 are particularly adapted for survival and growth in water at high temperatures even in the presence of chlorine, and (2) they possess a sufficient enzymatic complement of proteases and lechithinases so that in the presence of heat and hydration they can provoke an inflammatory reaction or infect the skin.
AJPH November, 1976, Vol. 66, No. 11
Although our limited study lends some support to the first hypothesis, prevalence should be examined in other areas, and the chlorine and temperature tolerance of serogroup 11 and other serogroups should be investigated. Studies of the exotoxins elaborated by serogroup 11 strains are underway, but clinical correlation should be established if, as seems likely, additional outbreaks occur. In that event, cultures of controls as well as cases would be helpful as would biopsies of affected skin. Replicating the skin rash with P. aeruginosa strains applied to superhydrated skin would strengthen an etiologic relationship. The increasing popularity of heated whirlpools for recreational as well as therapeutic purposes emphasizes the need for further investigations to clarify the relationship between Pseudomonas contamination of pools and rash illness in bathers.
Summary The isolation of Pseudomonas aerliginosa, serogroup 11, from the skin lesions of bathers and from public whirlpools during outbreaks of pool-associated rash illness raises the question of whether the association is an etiologic one and if so what accounts for it. We suggest that a particular environmental adaptation of some strains of Pseiudomonas and certain virulence factors they possess may enhance their pathogenic potential.
REFERENCES 1. McCausland, R. S., Cox, P. J. Pseudomonas infection traced to motel whirlpool. J. Environmental Health 37(5):455-459, 1975 2. Center for Disease Control. Skin rash associated with pool exposure-Minnesota. Morbidity and Mortality Weekly Rep 24(19):166-171, May 10, 1975 3. Center for Disease Control. Pool-associated rash illness-North Carolina. Morbidity and Mortality Weekly Rep 24(41):349-350, 1975 4. Black, A. P., Keirn, M. A., Smith, J. J. Jr., Dykes, G. M. Jr., Harlan, W.E. The disinfection of swimming pool water. Part 11. A field study of the disinfection of public swimming pools. Am J Public Health 60(4):740-750, 1970 5. Hoadley, A. W., Ajello, G., Masterson, N. Preliminary studies of fluorescent pseudomonads of growth at 41° C in swimming pool waters. Appl Microbiol 29(4):527-531, 1975 6. Favero, M. S., Carson, L. A., Bond, W. W., Petersen, N. J. Pseudomonas aeruginosa: Growth in distilled water from hospitals. Science 173:836-838, 1971 7. Hoadley, A. W., McCoy, E., Rohlich, G. A. Untersuchungen uber Pseudomonas aeruginosa in Oberflachengewassern. II. Auftreten and Verhalten. Arch Hyg 152:339-344, 1968 8. Taplin, D. in Clinical Dermatology; No. 3, Sect 3-16, p 1, New York, 1975 9. Taplin, D., Zaias, N., Rebell, G. Environmental influences on the microbiology of the skin. Arch Environ Health 11:546-550, 1965 10. Liu, P. V. The roles of various fractions of Pseudomonas aeruginosa in its pathogenesis. 11. Effects of lecithinase and protease. J Infect Dis 116:112-116, 1966 11. Hojyo-Tomoka, M. T., Marples, R. R., Kligman, A. M. Pseudomonas infection in super-hydrated skin. Arch Dematol 107:723-727, 1973
1093
the reason for visits to the physician, and the type of physician visited. The variation in response by diagnostic category seems somewhat idiosyncratic. We had anticipated a lower response rate for the more "intimate" diagnoses, such as vulvovaginitis and gynecology examination, or some consistent difference in response rate by severity of the diagnosis. The data do not suggest this kind of variation, however. For example, the diagnosis of pharyngitis (acute, self-limited) and that of hypertension (chronic, potentially serious) both had low rates of response.* The variation in response rate by physician suggests that the relationship between the physician and the patient may affect the level of response. Despite the lack of a certain explanation for the variation in response, our results will help to guide us in our future polling of patients and possibly help other projects estimate the response when attempting to obtain release of records for peer review or research purposes. *It is interesting to note that whatever the reasons for differences by diagnosis, they seem to apply to both the Washtenaw patients and the patients of another smaller sample (Wayne County); the Spearman rank order correlation between the diagnostic responses of the two counties was r, = 0.68, p < .05. This suggests some consistency in the effect of the diagnosis on the likelihood of responses to the permission request. Relationships between diagnosis and physician were not explored, however.
Summary 2,163 patients of 55 physicians in one county, were sent letters asking for their written permission to have their medical records audited by the University of Michigan research team. The overall positive response rate was 64.1 per cent for one county. Differences in response rates were statistically significant among specialties, among diagnoses, and among individual physicians.
REFERENCES 1. Payne, B. C., and Lyons, T. F. Detailed Statistics and Methodologies for Studies of Personal Medical Care in Hawaii, Ann Arbor, Michigan, University Microfilms, 1972. 2. Hulka, B. S., and Cassel, J. C., The AAFP-UNC study of the organization, utilization, and assessment of primary medical care, Am. J. Public Health, 63:494-501, 1973. 3. Hare, R. L., and Barnoon, S. Medical Care Appraisal and Quality Assurance in the Office Practice of Internal Medicine, San Francisco, California, American Society of Internal Medicine, 1973.
ACKNOWLEDGMENTS This project was supported by Grant No. ROI HS 01583 from the Bureau of Health Services Research, Health Resources Administration, HEW.
Pseudomonas aeruginosa Serogroup 1 1 and Pool-Associated Skin Rash JAY A. JACOBSON, MD, A. W. HOADLEY, PHD, AND JOHN J. FARMER, III, PHD Pseudomonas aeriuginosa has been isolated from the skin of affected persons in three outbreaks of rash illness associated with motel whirlpools that occurred in the United States within the past four years.1-3 In these outbreaks, the rash developed approximately one to three days after the bathers used the pool. It appeared on the trunk and limbs and was accentuated in areas that had been covered by a bathing suit. It resolved within a week without specific treatment. Attack rates among pool users in these outbreaks ranged from 53 percent to 85 percent. The evidence implicating P. aeruginosa as the etiologic Address reprint requests to Dr. Jay A. Jacobson, Bacterial Diseases Division, Bureau of Epidemiology, Center for Disease Control, Atlanta, GA 30333. Dr. Farmer is also at CDC; Dr. Hoadley is with the Georgia Institute of Technology, Atlanta. This paper, submitted to the Journal February 23, 1976, was revised and accepted
for publication July 6, 1976. 1092
agent is circumstantial. In no outbreak did rash occur in persons who did not use the whirlpool. Numerous environmental samples including carpeting, filters, drains, and, in one investigation,2 the whirlpool water itself, have been positive for P. aeruginosa. In the outbreaks P. aeruginosa, serogroup 11, was recovered from I of 2, 2 of 2, and 4 of 4 affected bathers who were cultured. Serogroup 4 was isolated from the affected skin of the other bather cultured in the first investigation. In 2 of the 3 investigations2' 3 isolates of serogroup 11 were recovered from environmental sources, including pool water. Serogroups other than 11 were cultured from pools in adjacent motels that were unassociated with cases of skin rash. The recurrent association between rash illness and whirlpools and the repeated isolation of a single serogroup of P. aeruginosa prompted the authors to conduct a limited study of P. aeruginosa contamination of whirlpools in the Atlanta, Georgia area. AJPH November, 1976, Vol. 66, No. 11
PUBLIC HEALTH BRIEFS
Water samples were obtained from whirlpools at six health spas, a motel, and an apartment complex. Chlorine content was measured by the orthotolidine test. Pool temperatures ranged from 360 to 420 C, pH from 5.8 to 7.8, and total chlorine residual from 0 to greater than 3.0 mg per liter. Seventeen (71 per cent) of 24 samples were positive for P. aeruginosa. In the positive samples the median most probable number (MPN) of organisms was 33/100 ml, and the populations of some exceeded 2400/100 ml. Although many of the samples contained multiple serogroups, serogroup 11 was demonstrated most frequently (7/17, 41 per cent). Coliforms with a median MPN of 25/100 ml were isolated from six (25 per cent) of 24 samples. P. aeruginosa was recovered from pools with and without coliform contamination, including pools that had acceptable levels of free chlorine.
Discussion The fact that P. aeruginosa grows in swimming pools and other moist environments has been amply documented,4' 5Its ability to grow at 42° C is a well established property,5 and it has also been shown to grow in distilled water6 and in surface waters.7 Thus, it is not surprising that the species may be recovered from the water and wet surfaces of heated whirlpools. Of concern, however, are the possible consequences this may have for pool users. Whether P. aeruginosa causes the rash illness is not entirely clear. The affected bathers' skin may simply have been colonized with the organism and their rash due to another agent such as a chemical irritant. Cultures of bathers who did not develop a rash would have helped to evaluate this possibility, but, unfortunately, they were not obtained. There are, however, several bits of experimental evidence that tend to support the view that P. aeruginosa could, indeed, be the cause of these outbreaks. First, while it is not part of the skin's normal flora,8 hydration of the skin and alteration of its normal flora appear to promote the growth of Pseudomonas.9 Second, some strains of P. aeruginosa produce exotoxins that cause inflammation, edema, and hemorrhage in the skin of test animals.10 Third, in aqueous solution, P. aerluginosa breaks down human callus.9 Fourth, pseudomonads were the predominant bacteria recovered from a pustular skin rash produced experimentally in volunteers by continuous wet occlusion of selected skin sites. 11 The corresponding prevalence of P. aertiginosa, serogroup 11, among isolates from patients and whirlpools led to our hypotheses that: (1) these strains of serogroup 11 are particularly adapted for survival and growth in water at high temperatures even in the presence of chlorine, and (2) they possess a sufficient enzymatic complement of proteases and lechithinases so that in the presence of heat and hydration they can provoke an inflammatory reaction or infect the skin.
AJPH November, 1976, Vol. 66, No. 11
Although our limited study lends some support to the first hypothesis, prevalence should be examined in other areas, and the chlorine and temperature tolerance of serogroup 11 and other serogroups should be investigated. Studies of the exotoxins elaborated by serogroup 11 strains are underway, but clinical correlation should be established if, as seems likely, additional outbreaks occur. In that event, cultures of controls as well as cases would be helpful as would biopsies of affected skin. Replicating the skin rash with P. aeruginosa strains applied to superhydrated skin would strengthen an etiologic relationship. The increasing popularity of heated whirlpools for recreational as well as therapeutic purposes emphasizes the need for further investigations to clarify the relationship between Pseudomonas contamination of pools and rash illness in bathers.
Summary The isolation of Pseudomonas aerliginosa, serogroup 11, from the skin lesions of bathers and from public whirlpools during outbreaks of pool-associated rash illness raises the question of whether the association is an etiologic one and if so what accounts for it. We suggest that a particular environmental adaptation of some strains of Pseiudomonas and certain virulence factors they possess may enhance their pathogenic potential.
REFERENCES 1. McCausland, R. S., Cox, P. J. Pseudomonas infection traced to motel whirlpool. J. Environmental Health 37(5):455-459, 1975 2. Center for Disease Control. Skin rash associated with pool exposure-Minnesota. Morbidity and Mortality Weekly Rep 24(19):166-171, May 10, 1975 3. Center for Disease Control. Pool-associated rash illness-North Carolina. Morbidity and Mortality Weekly Rep 24(41):349-350, 1975 4. Black, A. P., Keirn, M. A., Smith, J. J. Jr., Dykes, G. M. Jr., Harlan, W.E. The disinfection of swimming pool water. Part 11. A field study of the disinfection of public swimming pools. Am J Public Health 60(4):740-750, 1970 5. Hoadley, A. W., Ajello, G., Masterson, N. Preliminary studies of fluorescent pseudomonads of growth at 41° C in swimming pool waters. Appl Microbiol 29(4):527-531, 1975 6. Favero, M. S., Carson, L. A., Bond, W. W., Petersen, N. J. Pseudomonas aeruginosa: Growth in distilled water from hospitals. Science 173:836-838, 1971 7. Hoadley, A. W., McCoy, E., Rohlich, G. A. Untersuchungen uber Pseudomonas aeruginosa in Oberflachengewassern. II. Auftreten and Verhalten. Arch Hyg 152:339-344, 1968 8. Taplin, D. in Clinical Dermatology; No. 3, Sect 3-16, p 1, New York, 1975 9. Taplin, D., Zaias, N., Rebell, G. Environmental influences on the microbiology of the skin. Arch Environ Health 11:546-550, 1965 10. Liu, P. V. The roles of various fractions of Pseudomonas aeruginosa in its pathogenesis. 11. Effects of lecithinase and protease. J Infect Dis 116:112-116, 1966 11. Hojyo-Tomoka, M. T., Marples, R. R., Kligman, A. M. Pseudomonas infection in super-hydrated skin. Arch Dematol 107:723-727, 1973
1093
![[Nephrotic syndrome and skin rash].](/assets/img/hold.png)
