Following an item last year in What The Papers Say on the transmission of diseases in sports, we had a letter from a subscriber asking why swimming hadn't been included in the piece. 'I am worried,' she said, 'because I spend up to three hours a day in a public pool, and often see open sores on people. What about the sores that are covered up?' This is our (somewhat belated) response to her request, outlining the risks, infectious and otherwise, of using swimming pools.


HIV/Hepatitis A & B
Hepatitis A viral infection is transmitted by the faeco-oral route. Hepatitis B viral infection is transmitted by the blood-borne route. HIV is transmitted by body fluid secretions. There is virtually NO risk of contracting these infections from properly chlorinated pools. The recom-mended pool chlorination should maintain free chlorine residual of 3-5 mg/l, which should render all pools free from viral infection. (There are documented cases of Hepatitis A outbreaks from pools with gross faecal contamination that have not been fully cholorinated.)

Skin
1. Molluscum Contagiosum is a viral skin infection that is characterised by small flesh-coloured papules. It can be contracted by water-borne infection. The treatment is by cautery, either chemical or cryocautery.

2. Dermatitis, especially allergy. The allergic reaction may be to wet suits, masks or black suits. Treatment is with emollients, steroid cream and avoidance of the allergy-producing substance.

3. Plantar Warts (verrucae). These are very common and can be painful if situated over the pressure points. Treatment is with topical applications or cryocautery.


Ear
1. Otitis Externa (inflammation and/or infection of the outer ear canal) is very common in swimmers. The moistness in the ear canal from pool water predisposes to this condition. It can be prevented by placing in the ear canal either pledgets of cotton wool coated with jelly or commercial ear plugs coated with ointment. An acute attack is treated by gentle irrigation of the ear canal with normal saline liquid and subsequent instillation of antibiotic and/or anti-inflammatory drugs. It can also be prevented by instilling acetic acid 0.25% or 70% alcohol ear drops before and after swimming.

2. Eustachian tube dysfunction occurs due to barometric changes in swimmers, particularly divers and sub-aqua enthusiasts. The barometric changes cause an effusion to occur in the middle ear. This can be partially prevented following a dive by slowly blowing air out of the mouth while reaching the surface. Treatment is with topical nasal decongestants and sometimes antibiotic ear drops. Oral decongestants should NOT be taken as most of them are banned substances by IOC ruling. Rarely a myringotomy (a small surgical incision in the eardrum) has to be made.


Eye
Conjunctivitis (non-bacterial) may occur in swimmers because of sensitivity to chlorine. Acute treatment would be with steroid drugs, and prevention could be maintained with anti-inflammatory drugs such as Opticrom.

Gynaecological
1. In swimmers there is a slight increase in the vaginal infections that women get normally. Treatment consists of creams and/or pessaries.

2. There is no increase in the incidence of generalised pelvic infections.

3. During menstruation there is no bacterial contamination of the pool water. The use of intra-vaginal tampons during menstruation has made it both convenient and comfortable for most female swimmers.


Swimmer's shoulder
It should be remembered that the number of injuries in swimmers per 1000 man-hours of play is one of the lowest for all sports. The median days-off with injury is also very low.

Eighty per cent of the power in swimming comes from arm action, and the incidence of painful shoulders in swimmers ranges from 40-60 per cent. During the arm action, the humeral head abuts against the acromium and the coraco-acromial ligament. This impingement may irritate sub-adjacent structures. Pain is obvious when the arm is lifted above the horizontal plane, especially upwards and outwards, with the maximum pain at the angle of 90 degrees. There may be local tenderness and reduction of mobility when the pain is prolonged. In the chronic condition, the pain takes on a nagging character and may be present at rest and often at night.

Treatment consists of rest, moblity training, anti-inflammatory medication and physiotherapy. In chronic cases, steroid injections may be used or surgery to remove the coraco-acromial ligament.

Design of pools
Non-slip floors should be installed, and the deep end should be at the changing-room end of the complex. This prevents young people (usually males) dashing out of the changing rooms and diving into the shallow end, with the risk of cervical spine injury.

David Hooper