References[1] Sood A et al. Environ Health Perspect, 2007;115;262-6
[2] Falkinham J O III, Emerg Infect Dis, 9(7), 763-7, 2003
[3] Hanak V, et al, Mayo Clin Proc, 82/7), 812-6, 2007
Figure 3: Filter stored in water with hydrogenperoxide before the next use. Visible microbialgrowth on surfaces.
Conclusion
•Whirlpool spas may be an occupational healthproblem
•The way the facility is cleansed may increasethe risk for development of hot tub lung
•M. avium in cultures taken from water, filtersand patients supports the diagnosis of hot tublung
•After conversion to sand filter the hotel techni-cian’s exposure has decreased but the growthof M. avium in the whirlpool system remains
•Quantitative culture may be useful to monitorlevels of mycobacteria
Figure 4: Washing a filter with a water hose
Figure 5: Filtered (left) and spread (right) watersample
Figure 1: One of the hotel spa whirlpools
Results
Table 1: Summary of the seven casesResp.
Hotel Employee Alveolitis Symtomsa cultureA 1 Yes Yes M. avium
2 & 3 Suspected Yes Not doneB 4 & 5 No Yes M. aviumC 6 No Nob M. avium
7 No No M. aviumaFever, chills and dyspnea related to cleansingbOne patient, though, had flu like symptoms shortly afterbathing in the pool
Table 2: Differences between the three facilitiesHotel A Hotel B Hotel C
Use of high pressure washer Yes No NoSufficient ventilation No No YesVisible growth on surfaces Yes Yes YesPresence of M. avium in whirlpool Yes Yes YesPresence of other mycobacteria No Yes NoPresence of M. avium in fresh water No Yes NoDry storage of filter between use No No Yes
Figure 2: The cleaning system of the whirlpools; filter and UV-light
IntroductionHotel technicians cleaning spa whirlpools and fil-ters became ill with fever, chills and dyspnea re-lated to cleansing spa whirlpools (Table 1). In to-tal seven employees at three hotels in WesternSweden were involved. Three of them devel-oped so-called hot tub lung, which is an allergicalveolitis-like granulomatous lung disease [1–3].Mycobacterium avium was suspected to be thecause.
Methods
Investigation of the workplacesInspections of the sites were carried out by anoccupational hygienist.
The three whirlpools (36◦C) were from the samemanufacturer and designed for 5-10 persons.The water was cleaned by 1-2 nylon membranefilters and disinfected with 50 ppm hydrogen per-oxide and UV-light. The filters was exchangedand cleaned once a week by the hotel techni-cians. One filter was always being out of useand kept in a separate container (Table 2) .
The spa whirlpools at the three hotels were, assoon as the problems were recognized, con-verted to water purification by sand filter and hy-drogen peroxide and UV-light.
Sampling
Respiratory samples from the patients weresputum or obtained using bronchoscopy
Water samples were taken from pool water, filterwater and scrapings from filter surfaces
Microbiological analyses
•Direct microscopy was done on filter scrapings•Water was decontaminated with standard
methods for contaminated samples•The concentrated samples were then incu-
bated for eight weeks on Löwenstein-Jensenmedium
•A quantitive method was developed. 200 mLwater was centrifuged and decontaminated.The concentrated sample was then diluted to10 mL, from which 0.1 mL was spread on Mid-dlebrook 7H10 agar and the rest was filteredthrough a 0.45 µm filter, which was incubatedon 7H10 agar for eight weeks.
• Identification was done with GenoType Assay(Hain Lifescience, Germany) and AccuProbeM. avium kit (GenProbe, California, USA)
Mycobacterium avium alveolitis after cleansing hotel spa whirlpoolsErik Svenssona, Malin Ridella, Magnus Åkerströmb, and Eva AnderssonbaInstitute of Biomedicine, and bDepartment of Occupational and Environmental Medicine,
University of Gothenburg, Sweden
30th Annual Congress of the European Society of Mycobacteriology, 5-8 July 2009, Oporto, Portugal
