Severity and Economic Burden of Recreational Waterborne Illness in the United States

Surface water recreation on lakes, oceans, and rivers is popular in the United States. Currently, health outcomes that develop due to water recreation are typically assessed as a binary variable: illness is present or absent. Evidence suggests that a range of symptom severity exists among water recreators that may not be captured using a binary illness approach. The aims of this study were to characterize severity, describe potential predictors of severity, determine the cost of illness (COI) attributable to water recreation, and to estimate the economic burden due to recreational waterborne illness in the United States. Analyses used data from two prospective cohort studies. The Chicago Health Environmental Exposure and Recreation Study (CHEERS) focused on those participating in boating, fishing, and paddling on waters directly impacted by non-disinfected wastewater effluent. The National Epidemiological and Environmental Assessment of Recreational Water (NEEAR) study examined those swimming and wading at beaches impacted by human fecal pollution. This study observed a spectrum of illness severity among those who water recreate. Measures of water quality and direct water contact were associated with increased severity of symptoms among water recreators. The COI within NEEAR and CHEERS incorporated costs associated with medications, visits with a healthcare provider (HCP) or emergency department (ED), hospitalizations, and lost productivity. In general, the COI attributable to water recreation ranged between $500 to $2,000, per 1,000 individuals engaged in swimming, wading, boating, fishing, or paddling. The total economic burden due to recreational waterborne illness including sporadic GI, respiratory, eye, ear, and skin illnesses, and illnesses associated with recreational outbreaks, was estimated to range between $3.1 and $4.7 billion annually. This estimate included costs associated with medications, visits with an HCP or ED, hospitalizations, and costs related to missed work, mortality, and sequelae. Overall, assessing the occurrence of illness, may not adequately describe the impact of water recreation on human health. Severity and the COI may be promising for future studies of water recreation and health, while estimates of the total costs associated with recreational waterborne illness may be useful for prioritizing waterborne disease prevention initiatives.