Comprehensive Overview of Results

Analysis of All Splash Pad–Associated Outbreaks

Between 1997 and 2022, public health authorities across 23 states and Puerto Rico (illustrated in Figure 1) documented a total of 60 outbreaks linked to splash pads (as detailed in Table 1). These outbreaks stemmed from environments featuring solely splash pads (n = 39) and instances where splash pads were present alongside other recreational water facilities, such as swimming pools and hot tubs (n = 21). Cumulatively, these 60 outbreaks accounted for a staggering 10,611 reported cases, leading to 152 hospitalizations and 99 visits to emergency departments, with the notable absence of any fatalities.

Of the outbreaks, the etiology of waterborne disease was confirmed through laboratory analysis for approximately 52 (87%) out of the 60 cases (refer to Table 2). The protozoan parasite Cryptosporidium was identified as the causative agent in 40 (67%) of these outbreaks, which also included one outbreak associated with Giardia species and another linked to Shigella species. These cases resulted in a considerable total of 9,622 (91%) incidents, 123 (81%) hospitalizations, and 21 (21%) emergency department visits. Further analysis revealed that Cryptosporidium hominis was responsible for 14 (23%) of the outbreaks, corresponding to 7,833 (74%) of the total cases, 97 (64%) hospitalizations, and three (3%) emergency department visits. This species also accounted for the three largest outbreak incidents, totaling 2,307 cases, 2,050 cases, and 2,000 cases respectively; two of these were strictly splash pad outbreaks, while the third involved additional recreational water facilities. Interest in Cryptosporidium parvum revealed it to have contributed to four (7%) outbreaks, yielding just nine cases (<1%), two (2%) emergency department visits, and no reported hospitalizations. In 17 (28%) outbreaks, Cryptosporidium of unknown species was involved, resulting in 1,478 (14%) cases, 21 (14%) hospitalizations, and six (6%) emergency department visits. Additionally, three (5%) outbreaks involving multiple Cryptosporidium species produced 199 (2%) cases, 10 (10%) emergency department visits, and one (1%) hospitalization.

Other pathogens such as Shigella were responsible for five outbreaks (including one concurrent outbreak with Cryptosporidium), while Escherichia coli O157:H7 contributed to three outbreaks. Singularly attributed outbreaks were also noted for the following: Campylobacter jejuni, Giardia duodenalis (co-occurring with Cryptosporidium), norovirus, and Salmonella serotype Newport. Collectively, these 12 (20%) outbreaks resulted in 271 (3%) cases classified as acute gastrointestinal illness, 16 (11%) of which led to hospitalization, and six (6%) necessitated emergency department visits. Notably, Legionella pneumophila and chloramines were each confirmed as causative agents in individual outbreak cases. Out of the 99 emergency department visits tied to splash pad–associated outbreaks, a predominant 72 (73%) were associated with two outbreaks suspected of being linked to norovirus.

When looking at the timing of these outbreaks, 57 of the 60 reported during the peak months of May through August (illustrated in Figure 2). Interestingly, about one-fourth of the outbreaks (n = 17; 27%) were tied to at least one splash pad situated in a communal or municipal setting, followed by 14 outbreaks (23%) occurring in municipal parks (depicted in Figure 3).

Detailed Examination of Outbreaks Associated with Splash Pads Only

In a more focused analysis, the data on outbreaks strictly linked to splash pads were scrutinized separately to isolate the specific etiological agents and contributing factors, differentiating them from incidents tied to other treated recreational venues such as swimming pools and hot tubs. Out of the 60 outbreaks reported, 39 (65%) were attributed solely to splash pads, leading to 5,384 reported cases, 85 emergency department visits, and 68 hospitalization events (as outlined in Table 3). The etiology of these outbreaks was confirmed through laboratory testing for 33 (85%) of the 39 identified cases. A substantial number of these outbreaks, specifically 25 (64%), were attributed to Cryptosporidium, including one co-occurring case with Giardia and another with Shigella. These events accounted for an overwhelming 5,111 (95%) of the total cases represented, 9 (11%) of the emergency department visits, and 45 (66%) of the hospitalizations.

Diving deeper, C. hominis was recognized for causing nine (23%) outbreaks associated exclusively with splash pads, resulting in 4,551 (85%) cases, 33 (49%) hospitalizations, and no emergency department visits. C. parvum was involved in four (10%) outbreaks that collectively led to only nine cases (<1%), two (2%) emergency department visits, and no hospitalizations. Meanwhile, Cryptosporidium of unknown species propagated nine (23%) outbreaks, which yielded 436 (8%) cases, eight (12%) hospitalizations, and notably no emergency department visits. An additional singular outbreak involving multiple species of Cryptosporidium accounted for 22 (<1%) cases, four (5%) emergency department visits, and none requiring hospitalization.

From the 39 outbreaks linked exclusively to splash pads, Shigella species accounted for four outbreaks (with one overlapping with Cryptosporidium), while E. coli O157:H7 was responsible for two outbreaks. Each of the following also contributed to one outbreak: Campylobacter jejuni, G. duodenalis (overlapping with Cryptosporidium), norovirus, and Salmonella serotype Newport, together comprising 10 (26%) of the 39 outbreaks. These resulted in an additional 140 (3%) cases of acute gastrointestinal illness, 10 (15%) hospitalizations, and three (4%) emergency department visits. Out of the reported 85 emergency department visits associated with exclusively splash pad outbreaks, a significant 72 (85%) were linked to two occurrences suspected to be caused by norovirus. Chlorine was speculated to have played a role in causing a separate outbreak which resulted in 17 cases (<1%), one emergency department visit (1%), and zero hospitalizations.

Focusing on the seasonal aspect, a staggering 38 (97%) of the 39 outbreaks tied exclusively to splash pads occurred during the typical warm months of May through August (see Figure 2). An anomalous outbreak reported from Puerto Rico commenced in December. Community or municipal park settings were implicated in 14 (36%) of these splash pad-only outbreaks, while 13 outbreaks (33%) occurred within other municipal or community settings (as illustrated in Figure 3).

Among the 39 splash pad-exclusive outbreaks, data concerning contributing factors were documented in 27 (69%) cases (as summarized in Table 4). Within these 27 outbreaks, a collective total of 70 documented contributing factors were observed. Pertaining to cases specifically involving Cryptosporidium, common contributing factors documented included person-related factors (e.g., the primary intended use of the water by diaper/toddler-aged children) and facility design-related aspects (e.g., absence of supplemental disinfection mechanisms that could deactivate pathogens such as Cryptosporidium). For outbreaks linked to bacterial or viral agents, issues relating to maintenance were frequently noted (e.g., malfunction or lack of disinfectant control systems) alongside policy and management-related factors (e.g., inadequate water quality monitoring due to insufficient test kits or testing frequency). Notably, operator errors were also frequently recorded as common contributors across outbreaks caused by both Cryptosporidium and other bacterial or viral pathogens.

Role of AI legalese decoder in Understanding legal Implications

In light of these findings, understanding the complex legal landscape surrounding splash pads and health outbreaks can be daunting. This is where the AI legalese decoder can play a pivotal role. By offering a user-friendly platform that simplifies legal jargon, it helps stakeholders, including municipal facilities and park operators, navigate through regulations pertaining to health and safety. The AI legalese decoder can provide clear interpretations of liability issues arising from outbreaks, assisting in ensuring compliance with health codes and enhancing facility safety measures. Furthermore, it can aid in drafting effective safety protocols and responding to legally sensitive situations that can arise from health-related claims. By doing so, it empowers facility managers and legal counsel with the tools needed to make informed decisions, ultimately protecting both public health and operational integrity.