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Lam, Edward K. S., Vargha, Márta, Thomas, Daniel, Salmon, Roland, Kádár, Mihály, Figueras Salvat, Maria José, Brainard, Julii, Bartram, Jamie, Barna, Zsofia and Hunter, Paul R. 
ORCID: https://orcid.org/0000-0002-5608-6144
(2026)
A Randomised Controlled Trial Assessing Infectious Disease Risks from Bathing in Inland Recreational Waters.
International Journal of Hygiene and Environmental Health, 277.
ISSN 1618-131X
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Abstract
Evidence to determine the suitability of water quality standards to prevent illness from recreation exposure in inland waters is limited. We present a secondary analysis of previously unpublished data from four Hungarian freshwater sites included in the Epibathe study, a large randomised controlled trial. A total of 2368 participants were randomly allocated either to bathe for 10 min undertaking at least three head immersions, or to remain on the shoreside without water contact. Concurrent water sampling quantified individual-level faecal indicator organism densities and health outcomes were assessed at one-week follow-up. Generalised estimating equation models quantified the relative risk for adverse health outcomes for bathers versus shoreline-only (non-bather) participants, as well as the change in risk per unit increase in FIO concentration; crude, covariate-adjusted and covariate-adjusted models with multiple imputation are reported. Higher concentrations of Escherichia coli and somatic coliphage were each associated with increased risk of gastrointestinal illness (adj. RR = 1.73; 95% CI 1.13–2.65 and RR = 1.46; 95% CI 1.04–2.04 respectively). Bathing itself, independent of any individual microbial indicator, was associated with increased risk for skin ailments (adj. RR = 2.17; 95% CI 1.55-3.03). Low prevalence of eye, ear or respiratory infections precluded reliable estimation of exposure-response relationships. These findings confirm the value of E. coli and potential of somatic coliphage densities as indicators of freshwater quality relevant to recreation-associated gastrointestinal illness risk. In freshwater settings, E. coli and coliphages appear to be more informative than enterococci as predictors of gastrointestinal illness, contrasting with evidence from marine waters.
| Item Type: | Article |
|---|---|
| Additional Information: | Data and code availability: Available at https://github.com/edwardkslam/Epibathe |
| Uncontrolled Keywords: | escherichia coli,faecal enterococci,gastrointestinal illness,lakes,open water swimming,rivers,somatic coliphages,public health, environmental and occupational health,sdg 3 - good health and well-being,sdg 14 - life below water ,/dk/atira/pure/subjectarea/asjc/2700/2739 |
| Faculty \ School: | Faculty of Medicine and Health Sciences > Norwich Medical School University of East Anglia Research Groups/Centres > Theme - ClimateUEA |
| UEA Research Groups: | Faculty of Medicine and Health Sciences > Research Centres > Public Health Faculty of Medicine and Health Sciences > Research Groups > Epidemiology and Public Health Faculty of Social Sciences > Research Centres > Water Security Research Centre |
| Related URLs: | |
| Depositing User: | LivePure Connector |
| Date Deposited: | 26 Aug 2026 10:47 |
| Last Modified: | 01 Sep 2026 08:32 |
| URI: | https://ueaeprints.uea.ac.uk/id/eprint/104364 |
| DOI: | 10.1016/j.ijheh.2026.114888 |
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