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The volume of water ingested by swimmers while swimming is of great interest to individuals who develop risk assessments using quantitative microbial risk assessment or epidemiological approaches. We have used chloroisocyanurate disinfected swimming pool waters to determine the amount of water swallowed by swimmers during swimming activity. The chloroisocyanurate, which is in equilibrium with chlorine and cyanuric acid in the pool water, provides a biomarker, cyanuric acid, that once swallowed passes through the body into the urine unchanged. The concentration of cyanuric acid in a 24 hour urine specimen and the concentration in pool water can be used to calculate the amount of water swallowed. Our study population of 549 participants, which was about evenly divided by gender, and young and adult swimmers, indicated that swimmers ingest about 32 mL per hour (arithmetic mean) and that children swallowed about four times as much water as adults during swimming activities. It was also observed that males had a tendency to swallow more water than females during swimming activity and that children spent about twice as much time in the water than adults.

Cyanuric acid (CYA) excretion in urine has been used to estimate the volume of water ingested during swimming and other recreational activities in outdoor pools containing this chemical. These estimates of water ingestion are based on the assumption of 100% excretion within 24 hours, but the supporting evidence for this is scant. While adapting this methodology to investigate other water ingestion scenarios, we observed a high degree of variability in cyanuric acid excretion among experimental subjects, with over 25% of individuals excreting less than 80% of an ingested dose. Use of cyanuric acid to measure inadvertent water ingestion may be a valuable tool to generate data for health risk assessment of non-potable water sources, but our observations indicate that this technique carries an inherent degree of underestimation that should be taken into account when calculating water exposure.

Enteric pathogens in pool water can be unintentionally ingested during swimming, increasing the likelihood of acute gastrointestinal illness (AGI). AGI cases in outbreaks are more likely to submerge heads than non-cases, but an association is unknown since outbreak data are self-reported and prone to bias. In the present study, head submersion frequency and duration were observed and analyzed for associations with pool water ingestion measured using ultra high pressure liquid chromatography - tandem mass spectrometry. Frequency of splashes to the face was also quantified. Reliable tools that assess activities associated with pool water ingestion are needed to identify ingestion risk factors and at-risk populations. Objectives were to determine if the observed activities were associated with ingestion, and to test environmental sensor and videography assessment tools. Greater frequency and duration of head submersion were not associated with ingestion, but frequency of splashes to the face, leisurely swimming, and being ≤18 were. Videography was validated for assessing swimmer head submersion frequency. Results demonstrate ingestion risk factors can be identified using videography and urine analysis techniques. Expanding surveys to include questions on leisure swimming participation and frequency of splashes to the face is recommended to improve exposure assessment during outbreak investigations.

Chloroisocyanurates are commonly added to outdoor swimming pools to stabilize chlorine disinfectants. The chloroisocyanurates decompose slowly to release chlorine and cyanuric acid. Studies conducted to determine if the chloroisocyanurates might be toxic to swimmers showed that they were not and that ingested cyanuric acid passed through the body unmetabolized. This fact was used to determine the amount of water swallowed during swimming activity. Fifty-three recreational swimmers, using a community swimming pool disinfected with cyanuric acid stabilized chlorine, participated in the study. The participants did not swim on the day before or after the test swim. The swimmers were asked to actively swim for at least 45 minutes and to collect their urine for the next 24 hours. Cyanuric acid was measured in pool water using high performance liquid chromatography and porous graphitic carbon columns with UV detection. The urine sample assay required a clean-up procedure to remove urinary proteins and interfering substances. Results of the study indicate that non-adults ingest about twice as much water as adults during swimming activity. The average amount of water swallowed by non-adults and adults was 37 ml and 16 ml, respectively. The design for this study and the analytical methodology used to assay cyanuric acid in swimming pool water and human urine were effective for measuring the volume of water swallowed during swimming activity.