Relationship of Microbial Indicators to Health Effects
At Marine Bathing Beaches
VICTOR J. CABELLI, PHD, ALFRED P. DUFOUR, PHD, MORRIS A. LEVIN, PHD,
LELAND J. MCCABE, PE, MHP, AND PAUL W. HABERMAN, MBA
Abstract: Findings are described from the second
year of an epidemiological-microbiological study con-
ducted at New York City beaches as part of the U.S.
Environmental Protection Agency program to develop
health effects-recreational water quality criteria.
Symptomatology rates among swimmers (defined as
immersion of the head in the water) relative to non-
swimming but beach-going controls at a "barely ac-
ceptable" (BA) beach and a "relatively unpolluted"
(RU) beach were examined. Data were collected by
contacting family groups at the beach on weekends,
obtaining information on bathing activity, and then
questioning them by phone some 8-10 days later. In
Discharge via outfalls into ocean and estuarine waters
remains the most common means for the disposal of sewage
effluents by coastal communities. Therefore, there is a con-
tinuing requirement for sewage effluent guidelines, set on a
plant-by-plant basis and derived from criteria and guidelines
at potentially impacted targets such as bathing beaches and
shellfish-growing areas. Existing recreational water quality
criteria, guidelines, and standards have been reviewed by
McKee and Wolf in 1963,' by Senn, et al,2 in the same year
and, more recently, by Mechalas, et al.3 The microbiological
guideline for direct contact recreational waters recommend-
ed by the National Technical Advisory Committee (NTAC)
to the Federal Water Pollution Control Administration in
1968,4 set forth by the U.S. Environmental Protection Agen-
cy in 1976,5 and used in many states, is a geometric mean
fecal coliform density of 200 per 100 ml of water.* The guide-
line was based on findings reported by Stevenson in 19536
*As determined by multiple-tube fermentation or membrane fil-
ter procedures based on a minimum of not less than five samples
taken over not more than a 30-day period, the fecal coliform content
of primary contact recreation waters shall not exceed a log mean of
200/100 ml, nor shall more than 10 per cent of total samples during
any 30-day period exceed 400/100 ml.
Address reprint requests to Victor J. Cabelli, PhD, Marine
Field Station, Health Effects Research Laboratory-Cin., U.S. Envi-
ronmental Protection Agency, Liberty Lane, West Kingston, RI
02892. Authors Dufour and Levin are also at HERL-Cin.; Mr.
McCabe is with HERL, Cincinnati, OH; Mr. Haberman is with the
Center for Policy Research, New York, NY. This paper, submitted
to the Journal July 3, 1978, was revised and accepted for publication
December 6, 1978.
690
addition measurements were made for a number of po-
tential water quality indicators.
It was observed that the symptom rates, cate-
gorized as gastrointestinal (GI), respiratory, "other",
and "disabling" (stayed home, stayed in bed, consult-
ed a physician), were higher among swimmers than
nonswimmers. As in the pretest conducted the pre-
vious year, the rate of GI symptoms was significantly
higher among swimmers relative to nonswimmers at
the BA but not the RU beach. Children, Hispanic
Americans, and the low-middle socioeconomic groups
were identified as the most susceptible portions of the
population. (Am J Public Health 69:690-696, 1979.)
from epidemiological studies conducted on Lake Michigan
and the Ohio River. As noted by the Senn committee,2 Hen-
derson,7 and many other workers since then,8 a major diffi-
culty with the NTAC guidelines or any microbiological guide-
line or standard for recreational waters is the paucity of rele-
vant epidemiological information and the seemingly contra-
dictory findings from the two major efforts to obtain the re-
quired data, those of Moore9 and Stevenson.6 With regard to
the development of criteria, even the excellent analysis of a
recent outbreak of swimming-associated shigellosis'0 is want-
ing in that it does not provide data on the quality of the water
at the time of exposure, a frequent problem in the retro-
spective analyses of outbreaks. Henderson's and Moore's
objections notwithstanding, there is a requirement for health
effects, recreational water quality guidelines and standards.
If for no other reason, they are needed, as Shuval"I points
out, in setting design and operating criteria for municipal
sewage treatment plants and in locating their outfalls relative
to potential recreational resources.
Recognizing the need as stated above, the U.S. Envi-
ronmental Protection Agency has been conducting a pro-
gram to develop health effects-recreational water quality cri-
teria for marine and fresh waters. The overall program calls
for studies at a number of different geographic locations in
order to develop some general relationship between swim-
ming-associated illness as measured by symptomatology, to
some potential microbial indicator of water quality. The re-
sults to be presented at this time were obtained during the
second year of the study at New York City beaches; appro-
priate data from the first year (pretest), are also presented.
Some of the findings from the pretest were described ear-
lier. 12, 13 <
AJPH July, 1979, Vol. 69, No. 7

Materials and Methods
The overall study at the New York City beaches, the
experimental design, and the rationale for the design relative
to those used in previous studies were described in an earlier
publication. I2 The study was conducted in three phases. The
first phase, a pretest of the epidemiological and micro-
biological methodology, was performed during the summer
of 1973; the second phase was conducted during the summer
of 1974. The major objective of the study was the examina-
tion of symptom rates for swimmers relative to non-
swimming controls at a "barely acceptable" (BA) as com-
pared to a "relatively unpolluted" (RU) beach. A barely ac-
ceptable beach was defined as the most "polluted" beach
available which was not posted as being unsafe for recrea-
tional use according to local criteria. A relatively unpolluted
beach was defined as a beach which was subject to the least
amount of pollution and at which the populations were de-
mographically comparable to those at the BA beach.
The "important" illnesses and the "correct" indicators
of the quality of the water were treated as unknowns. There-
fore, illness information was sought in the context of symp-
tomatology; and measurements were made for a number of
potential water quality indicators. Briefly, the design con-
sisted of a series of discrete study periods during which: 1)
the potential participants, primarily as family groups, were
contacted at the beach on weekends; 2) individuals who
swam in the midweeks immediately before and after the
week-end were eliminated from the study; 3) measurements
for a number of potential water quality indicators were made
during the course of the study periods at the test beaches;
and 4) follow-up information concerning symptomatology
and demographic characteristics was solicited by phone
some 8-10 days after the beach interview. The design dif-
fered from that used in Stevenson's prospective studies6 in
that swimming was defined more stringently as exposure of
the head to the water and discrete trials were conducted over
relatively short periods of times (1-2 days). Thereby, the ef-
fects of day-to-day variability in pollution level reaching the
test beaches were minimized. In addition, a beach-going but
nonswimming control population was obtained. During 1973
and 1974, an area in the vicinity of 20th Street at Coney Is-
land was used as the BA beach, chosen because it is a heavi-
ly used beach area immediately adjacent to one that was
posted as unsafe for swimming according to local standards.
During 1974, Riis Park in the Rockaways was used as the RU
beach, a change from Rockaways 67th Street used in 1973.
The change was necessary in order to increase the size of the
study population. The densities of the various microbial in-
dicators were comparable at both Rockaways beaches.
Beach activity information was used to categorize the
participants as either swimmers (in the water for 10 minutes
or more, head and face actually immersed therein) or non-
swimmers. The symptoms for which queries were made and
the categories into which they were grouped will be de-
scribed under "Results". An estimate of disability was ob-
tained by asking whether the respondents remained home,
remained in bed, or sought medical advice; hospitalization
was not reported by any of the subjects, and the observation
AJPH July, 1979, Vol. 69, No. 7
MICROBIAL INDICATORS AT MARINE BATHING BEACHES
period was too short to identify illnesses with long in-
cubation periods. Demographic information included age,
sex, ethnicity, and socioeconomic status as reflected by a
persons to rooms ratio.
Water samples were collected periodically during the
time of maximum swimming activity at the beaches. Two
samples were collected from each beach at approximately
1 1:00 am, 1:00 pm, 3:00 pm and 5:00 pm. The samples were
collected at chest depth approximately four inches below the
surface of the water. Upon collection, the samples were iced
and delivered to the laboratory where they were assayed
within eight hours of collection. Total and fecal coliform
densities were obtained using the most probable number pro-
cedure as described in Standard Methods for the Examina-
tion of Water and Wastewater.'4 The densities of total coli-
forms and the component genera thereof (Escherichia, Kleb-
siella, Citrobacter-Enterobacter) were also measured using
the mC procedure of Dufour and Cabelli.15 Enterococci,16
Pseudomonas aeruginosa,17 and Clostridium perfringens'8
densities were determined using membrane filter procedures
developed in this laboratory. Enterovirus densities were not
examined for a number of reasons including problems in
methodology and logistics. Shigellae were not quantified be-
cause of methodology problems. Salmonella densities were
not obtained during the second year of the study because of
the very low densities observed during the pretest.12
The symptom rates, categorized as respiratory, gastro-
intestinal (GI), "other", and disabling, for swimmers and
nonswimmers at the BA and RU beaches were analyzed sta-
tistically by Cochran's two-way, chi-square analysis of asso-
ciation.'9 During the 1974 trials, in contrast to the pretest
conducted the previous year, gastrointestinal symptom-
atology was analyzed by demographic group in order to iden-
tify the sensitive portions of the populations. In addition,
during the 1974 trials, the credibility of the information ob-
tained on GI symptomatology was examined by comparing
the rates and trends for total GI symptoms to those for the
"highly credible" portion thereof. "Highly credible" symp-
toms included all cases of vomiting, instances of diarrhea
which were accompanied by a fever or which were disabling,
and cases of nausea and stomachache which were accom-
panied by a fever.
Results
The data presented herein were obtained from follow-up
telephone questionnaires during the 1974 trials. As can be
seen from Table 1, the response rate to follow-up phone
questionnaires among individuals who gave a phone number
during the course of the beach interview was about 80 per
cent at both beaches. This response rate was considered sat-
isfactory with the understanding that the findings have rele-
vance only to that portion of the overall New York City pop-
ulation which have telephones. Only 2.6 per cent of the
beach interviewees did not have phones. An additional 19
per cent of those approached were either uncooperative dur-
ing the beach interview, were midweek swimmers, or were
not from New York City.
691
CABELLI, ET AL
TABLE 1-Follow-up Rates for Telephone Questionnaires at
the Barely Acceptable (BA) and Relatively Unpol-
luted (RU) Beaches, 1974.
Category BA Beach RU Beach
Total for whom a phone 4020 5936
number was given at beach
No follow-up phone 874 1013
interview
No answer wrong phone 728 890
number, disconnected
phone
Uncooperative, unspecified 146 123
% Success 78.3 82.9
The study population, individuals for whom follow-up
questionnaires were obtained and who did not swim in the
midweeks before and after a weekend trial, consisted of ap-
proximately 8,000 individuals in four subpopulations, swim-
mers and nonswimmers at the BA and RU beaches. They
were distributed demographically as shown in Table 2. The
demographic characteristics of the beach interviewees and
those successfully followed-up were comparable. The char-
acteristics of the four subpopulations was not as comparable
in 1974 as in the 1973 pretest, particularly as regards ethnici-
ty and persons/room ratio.
As in 1973, about two-thirds of the beachgoers were
classified as "swimmers"; and there were no striking dif-
ferences between the Coney Island and the Rockaways pop-
ulations with regard to the percentage so classified. Swim-
ming was more frequent among males, Hispanic Americans,
and the 0-19 years of age groups. Of the nonswimmers at the
Coney Island and the Rockaways beaches, only 8.5 per cent
and 5.4 per cent respectively did not go swimming because
of existing symptoms or illness. None of the individuals at
the BA beach and only 0.1 per cent of those at the RU beach
did not go swimming because of GI symptomatology.
The attack rates for the various symptoms as reported
by telephone interview 8-10 days after the beach interview by
swimmers and nonswimmers at the two beaches are given in
Table 3. The most striking findings were the increases in the
rates of vomiting, diarrhea, and stomachache among swim-
mers relative to nonswimmers at the BA but not at the RU
beach. To a somewhat lesser extent, the same results were
obtained with the questions characterizing disability. Ear,
eye, nose, and skin symptomatology as well as fever were
higher among swimmers than non-swimmers at both
beaches.
The rates for the broad categories, themselves (gastro-
intestinal, respiratory, other, and disabling) for swimmers
and nonswimmers at both beaches, with the levels of signifi-
cance as determined from Cochran's two-way chi-square
analysis of association for the 1974 data are shown in Table
4. Except for the "'other" category, the rates were higher for
*33 percent at the Coney Island (BA) beach and 7.5 per cent at
the Rockaways (RU) beach.
692
swimmers than for nonswimmers at both beaches, but the dif-
ferentials in rates (swimmers minus nonswimmers) were
higher at the BA than at the RU beach. The only statistically
significant difference was the GI symptoms between swim-
mers and non-swimmers at the BA beach. The attack rates
for the four subpopulations (swimmers and nonswimmers at
both beaches) were adjusted for each demographic category
relative to that for the total samples (Table 5). The dif-
ferential in rates for gastrointestinal and disabling symptoms
at both beaches were not changed appreciably by the adjust-
ments.*
The results from the analysis of GI symptom rates by
demographic groups for swimmers and nonswimmers at both
beaches are presented in Table 6. The rates among children,
Hispanic-Americans, and low-middle socioeconomic indi-
viduals who swam at Coney Island were significantly and
appreciably higher than among those who did not. This was
not so for the residual from each demographic category
(adults, blacks plus whites, and the highest SES group). The
GI symptom rates for nonswimmers among the children at
the RU beach were appreciably higher than those for the cor-
responding groups at the BA beach. The rate for non-
swimming children at the RU beach was significantly higher
than that for children who swam.
Secondary transmission of illnesses within a family
could provide an erroneous picture of the symptom rates as-
sociated with swimming. Therefore, those instances in
which more than one individual in a family group reported
gastrointestinal symptoms were identified in the telephone
interview. There were 24 such instances, 13 at the BA beach
and 11 at the RU beach. In all but three, two at the BA beach
and one at the RU beach, the onset of symptoms for any two
members of the same household was within a two-day peri-
od.
The credibility of the information on gastrointestinal
symptomatology was assessed by comparing the trends of all
responses to those considered "highly credible".** The
rates for the "highly credible" symptoms among the four
study groups were examined for the total population and
separately for children, Hispanic-Americans, and the low to
middle socioeconomic groups. The trends for the highly cred-
ible portion (Table 7) were similar to those for all GI symp-
toms (Table 6). Rates of "highly credible" GI symptoms for
the three most sensitive groups of swimmers also were sig-
nificantly higher than those for their nonswimming controls.
Microbiological findings are presented in Table 8. Ap-
preciable and statistically significant differences in the den-
sities of a number of potential water quality indicators were
obtained at the BA as compared to the RU beach. These
findings were similar to those obtained the previous year.12
*
The 1974 data for disabling GI symptoms by type were not an-
alyzed statistically because of the small size of the resultant cells.
The disabling GI symptom rate for swimmers was 10/1000 higher
than that for non swimmers at the BA beach. At the RU beach, the
rate for nonswimmers was higher than that for swimmers by 2/1000.
** 1) all cases of vomiting, 2) cases of diarrhea accompanied by
a fever or a disability response, and 3) cases of nausea and stom-
achache accompanied by a fever.
AJPH July, 1979, Vol. 69, No. 7
 MICROBIAL INDICATORS AT MARINE BATHING BEACHES

TABLE 2-Demographic Characteristics of the Four Subpopulations, 1974

Per Cent of Respondents by Category

BA Beach RU Beach

Demographic Swim Nonswim Swim Nonswim

Group (N = 1961) (N = 1185) (N = 2767) (N = 4156)

Sex
Male 47.3 35.6 52.1 37.5
Female 52.7 64.4 47.9 62.5
Age Group (years)
0-9 26.4 19.5 16.2 12.5
10-19 31.1 16.4 23.4 11.9
20-39 32.4 45.0 45.6 57.0
5;40 10.1 19.1 14.8 18.6
Ethnic Group
Hispanic-American 54.3 46.3 20.1 16.0
White 28.5 33.3 68.7 70.9
Black 17.2 20.4 11.2 13.1
Persons/room ratioa
Z0.9 26.9 32.1 46.1 51.0
1.0-1.3 48.4 44.2 43.1 40.2
,1.4 24.7 23.7 10.8 8.8
aNumber of persons in household divided by number of rooms in household, as an indicator of socioeconomic
status (SES); 0.9 or less persons/room indicates higher SES; 1.0-1.3, middle SES; and 1.4 or more, lower SES.

TABLE 3-Reported Symptom Rates* among Swimmers and Nonswimmers at the BA and RU
Beaches
Rate/1000 at BA Rate/1000 at RU

Symptom Swim Nonswim Swim Nonswim

Gastrointestinal
Vomiting 10 6 9 9
Diarrhea 17 9 16 16
Stomachache 23 14 21 21
Nausea 11 12 12 14
Respiratory
Sore throat 22 24 28 31
Bad cough 15 10 14 13
Chest cold 13 15 12 13
Runny or stuffed nose 21 18 29 24
Earache or runny ears 17 11 19 13
Red, itchy or watery eyes 16 13 14 11
(>1 day), styes
Other
Fever(>1000 F) 16 12 14 8
Headache (>few hrs) 23 21 21 27
Backache 10 11 8 14
Skin rash, itchy skin, welts 30 21 32 25
Sneezing, wheezing, tight chest, 18 16 19 13
breathlessness (>5 min)
Non-specific
Bothersome sunburn 13 8 18 25
Disabling
Home because of symptoms 35 26 23 19
In bed because of symptoms 23 19 15 14
Medical help because of symptoms 14 11 15 13
*An individual with multiple symptoms may be counted in more than one category and in more than one group
within a category.

AJPH July, 1979, Vol. 69, No. 7 693

CABELLI, ET AL

TABLE 4-Symptom Rates per 1000 by Category* for 1974 at vice. These effects occur at pollution levels below most
the BA and RU Beaches existing guidelines and standards as seen from microbial in-
dicator densities. They are consistent with those reported
Symptom Rates* per 1000 persons at during the pretest year12 and those reported by Stevenson
BA Beach RU Beach
from the Ohio River study.6 They are not inconsistent with
those reported by Moore9 since neither poliomyelitis nor sal-
Symptom
Type Swim Nonswim A Swim Nonswim A monellosis were reported in the present study.
There are a number of questions concerning the design
N 1961 1185 2767 2156 and results of the study which might affect the conclusions
Respiratory 72 64 8 83 78 5 drawn. The credibility of symptoms as reported by the par-
GI 42a 26 16 39 35 4 ticipants or their parents could be questioned in the absence
Other 73 67 6 86 77 9
Disabling 38 29 9 30 26 4 of follow-up clinical and laboratory findings. An attempt was
made to obtain such follow-up information during the pre-
*An individual with multiple symptoms can be counted in several cate- test. However, the relatively benign nature of the symptoms,
gores but only once within a category. the lack of response of the study population to our request
aSignificantly (P = 0.005) higher than nonswimmers. for a phone call at their onset, and logistic considerations
made this impossible. The alternative was the analysis of
"highly credible" symptoms (as described); we interpret the
Discussion findings obtained as indicative of credible reporting on the
part of the respondents.
The data presented herein suggest that there are mea- Demographic differences among the four study popu-
surable health effects associated with swimming in sewage lations, particularly those relating to age, ethnicity, and per-
polluted waters. These effects are manifest primarily as rela- sons/room ratio, could have confounded analysis of the data
tively high rates of gastrointestinal symptoms among chil- and the conclusions drawn. However, the generally obtained
dren. Although no hospitalization was reported, the symp- demographic comparability of the swimmers to their non-
toms were severe enough in about one-half the cases for the swimming controls, the absence of appreciable differences in
individual to remain home, stay in bed, or seek medical ad- the residual rates for GI and disabling illnesses when the

TABLE 5-Adjustment of Symptom Rates in the Four Subpopulations for Demographic Dif-
ferences, 1974
Symptom Rates per 1000 persons at

Symptom Type/ BA Beach RU Beach

Adjustment fora Swim Nonswim A Swim Nonswim A

Respiratory
Unadjusted 72 64 8 83 78 5
Sex 72 65 7 84 79 5
Age group 74 70 4 84 79 5
Ethnic group 74 64 10 79 75 4
Persons/room ratio 80 73 7 91 81 10
Gastrointestinal
Unadjusted 42 26 16 39 35 4
Sex 43 24 19 39 35 4
Age group 38 25 13 39 38 1
Ethnic group 44 30 14 37 31 6
Persons/room ratio 48 31 17 43 38 5
"Other"
Unadjusted 73 67 6 86 77 9
Sex 74 66 8 87 78 9
Age group 81 66 15 89 77 12
Ethnic group 74 72 2 85 72 13
Persons/room ratio 84 74 10 96 81 15
Disability
Unadjusted 38 29 9 30 26 4
Sex 39 29 10 31 26 5
Age group 36 28 8 33 28 5
Ethnic group 37 30 7 30 25 5
Persons/room ratio 43 33 10 34 29 5

aRate adjustments based on demographic characteristics of total sample. Sex: male, 44.4; female, 55.6. Age
group: 0-9 years, 18.2; 10-19 years, 21.2; 20 or more, 60.6. Ethnic group: Hispanic-American, 31.1; White, 54.4;
Black, 14.5. Persons/room ratio: 0.9 or less, 40.6; 1.0-1.3; 43.8; 1.4 or more, 15.6.

694 AJPH July, 1979, Vol. 69, No. 7

 MICROBIAL INDICATORS AT MARINE BATHING BEACHES

TABLE 6-Analysis of Gastrointestinal Symptom Rates by De- TABLE 8-Geometric Mean Densities of Potential Microbial In-
mographic Grouping, 1974 dicators at the BA and RU Beaches, 1974
GI Symptom Rates per 1000 persons Log Mean
Recovery/100 ml at
BA Beach RU Beach
Demographic Indicator Methoda BA Beach RU Beach
Group Swim Nonswim Swim Nonswim
Total coliforms MPN 1213.* 43.2
Total sample 42' 26 39 35 Fecal coliforms MPN 565.* 28.4
Childrena 57fg 14 23f 55 Escherichia coli mC 15.3* 2.4
Hispanic-American 45fg 17 24 12 Klebsiella mC 59.2* 3.5
Low-Middle Persons/roomb 42t 16 41 34 Enterobacter-Citrobacter mC 434.* 6.6
Ratio Fecal streptococci mSD 16.4* 3.5
Adultsc 37 29 42 32 Pseudomonas aeruginosa mPA 45.8* 3.1
Non-Hispanic-Americansd 38 35 43 39
Highest persons/room 42 45 37 35 aSee "Materals and Methods"
ratioe *Significantly different at the 0.05 level

a;10
b
yrs. old.
51.0 persons/rooms ratio.
C>10 yrs. old.
dwhite and black.
e<1 .0 persons/rooms ratio.
fsignificantly different (P-0.05) than nonswimming control.
gsignificantly higher (P-.05) than RU swimmers.
GI-gastrointestinal; BA-barely acceptable; RU-relatively unpolluted.
rates were adjusted, and the results of the analysis of GI
symptomatology by demographic grouping tend to minimize
this possibility.
There is the concern with the higher rates for GI symp-
toms among the nonswimmers at the Rockaways relative to
those at Coney Island, especially since the swimmer rates
for the two beaches generally were not significantly different
from each other. There are a number of beach, home, and
population factors which could produce this situation. For
this reason, the study was designed so that the control popu-
lation for the swimmers was nonswimmers at the same
beach.
The anomolous finding of a significantly higher rate of
TABLE 7-Attack Rates for "Highly Credible"a Gastrointestinal
Symptoms
Symptom Rate per 1000 persons
GI symptoms for nonswimmers relative to swimmers at the
RU beach probably was not due to overreporting, since this
was also true of the "highly credible" portion. The non-
swimming children may have been more prone to illness, al-
though only 0.1 per cent of these children or their respond-
ents reported that they did not swim because of existent GI
symptoms. We favor the explanation that predominantly
white or black, higher SES children did not or were not al-
lowed to swim because they were in the early stages of the
illnesses for which they later reported symptoms.
The finding of a statistically significant, swimming-asso-
ciated rate of GI symptomatology at a "barely acceptable"
but not at a "relatively unpolluted" beach shows that beach
effects can be measured and suggests that measurable health
effects do occur even within existing guidelines and stan-
dards. However, these results do not speak to the overall
objective of this program, the development of criteria ame-
nable to risk analysis. This is perceived as a dose-response
type relationship of swimming-associated GI symptom-
atology to the quality of the water as determined from the
most appropriate water quality indicator. Additional data
from other locations will be needed and are being obtained to
achieve this objective.

BA Beach RU Beach
REFERENCES
1. McKee JE and Wolf HW Water Quality Criteria 2nd Ed. Pub-
Demographic lication No. 3A, State Water Quality Control Board, Sacra-
Group Swim Nonswim Swim Nonswim mento, Ca, pp. 28-63, 118-122, 1963.
2. Senn CL, Berger BB, Jensen EC et al: Coliform standards for
Total 16 9.3 12 12 recreational water. Progress report, Public Health Activities
Children 24h <4.5 9.2h 28 Committee, Sanitary Engineering Division, J San Eng Div
Hispanic-Americans 21 h 7.6 5.6 3.0 89:57-94, 1963.
Low-middle persons/ 141 5.2 15 10 3. Mechalas BJ, Hekimian KK, Schinazi LA and Dudley RH: An
room ratio Investigation into Recreational Water Quality. Water Quality
Adults 13 11 12 9.5 Criteria Data Book, Vol 4, U.S. Environmental Protection
Non-Hispanic- 10 11 13 13 Agency, Washington, DC, 1972.
Americans 4. National Technical Advisory Committee. Water Quality Cri-
Highest persons/ 21 17 9.1 13 teria. Federal Water Pollution Control Administration, Dept. of
room ratio Interior, Washington, DC, p. 7-14, 1968.
5. U.S. Environmental Protection Agency. Quality Criteria for
aAll instances of vomiting, diarrhea with fever or a disability response, and Water. USEPA, Washington, DC, p. 42-50, July 1976.
nausea and stomachache with fever. 6. Stevenson AJ: Studies of bathing water quality and health. Am J
hSignificantly different (P-0.1) than nonswimming control. Public Health. 43:529-538, 1953.

AJPH July, 1979, Vol. 69, No. 7 695

CABELLI, ET AL

7. Henderson MJ: Enteric disease criteria for recreational waters.
J San Eng Div 94:1253-1276, 1968
8. National Academy of Science-National Academy of Engineer-
ing. Water Quality Criteria 1972. US Govt. Printing Office,
5501-00520, p. 398-401, 1972.
9. Moore B: Sewage contamination of coastal bathing waters in
England and Wales. A bacteriological and epidemiological
study. J Hyg 57:435-472, 1959.
10. Rosenberg ML, Hazlet KK, Schaefer J, et al: Shigellosis from
swimming. JAMA 236:1849-1852, 1976.
11. Shuval HE: The case for microbial standards for bathing
beaches. In: Discharge of Sewage from Sea Outfalls. H. Game-
son, Ed. Pergamon, London, p. 95-101, 1975.
12. Cabelli VJ, Levin MA, Dufour AP and McCabe LJ: The devel-
opment of criteria for recreational waters. In: Discharge of Sew-
age from Sea Outfalls. Pergamon, London, p. 63-73, 1975.
13. Cabelli VJ, Dufour AP, Levin MA and Haberman PW: The im-
pact of pollution on marine bathing beaches: An epidemiological
study. In: Middle Atlantic Continental Shelf and the New York
Bight. Limnol and Oceano Sp Symp, 2:424-432, 1976.
14. American Public Health Association: Standard Methods for the
Examination of Water and Wastewater. 13th ed. American Pub-
lic Health Association Inc., New York, 1971.
-15. Dufour AP and Cabelli VJ: Membrane filter procedure for
enumerating the component genera of the coliform group in sea-
water. J Appl Microbiol 29:826-833, 1975.
16. Levin MA, Fischer JR and Cabelli VJ: Membrane filter tech-
nique for enumeration of enterococci in marine waters. J Appl
Microbiol 36:66-71, 1975.
17. Levin MA and Cabeili VJ: Membrane filter technique for enu-
meration of Pseudomonas aeruginosa. J Appl Microbiol
24:864-870, 1972.
18. Bisson JS and Cabelli VJ: A membrane enumeration method for
Clostridium perfringens. Abst Ann Meet Amer Soc Microbiol,
p. 206, 1978.
19. Fleiss JF: Statistical Methods for Rates and Proportions. John
Wiley and Sons, New York City, pp. 109-144, 1973.
ACKNOWLEDGMENTS
Portions of this paper were presented at the Annual Meeting of
the American Public Health Association held in Chicago, November
16-20, 1975.

I Nathalie Masse Memorial Committee*

In 1976, many friends of Dr. Nathalie Masse* established a Memorial to perpetuate her memory: to
fulfill this purpose a fellowship and an international prize were created.
1) The Nathalie Massee Research Fellowship
This fellowship (granted in even-numbered years) was awarded last year for the first time for a
research on nutrition education in a socially deprived region of South America.
The next fellowship, to be awarded in 1980, is likewise intended for young research workers. It is
intended to help them in their projects directed to problems in social and preventive pediatrics.
2) The International Nathalie Masse Prize
This prize, amounting to 10,000 French francs, will be awarded for the first time in 1979, and every
2 years thereafter.
It is intended as compensation for an original work concerning childhood, prepared by an institu-
tion or an individual under 40 years of age, with a view to encouraging studies by young professionals or
research workers.
In both cases, the winners will be chosen without regard to nationality by an international jury.
The detailed rules concerning the Fellowship and the Prize, as well as application forms, may be
obtained by writing to Memorial Committee, International Children's Centre, Chaiteau de Longchamp,
Bois de Boulogne, 75016 Paris.

*Dr. Nathalie Masse, who died in 1975, was director of teaching at the International Children's Centre for 18
years. She made major contributions to the improvement of child health internationally.

696 AJPH July, 1979, Vol. 69, No. 7

This article has been cited by:

1. Shannon McGinnis, Susan Spencer, Aaron Firnstahl, Joel Stokdyk, Mark Borchardt, David T. McCarthy, Heather
M. Murphy. 2018. Human Bacteroides and total coliforms as indicators of recent combined sewer overflows and rain
events in urban creeks. Science of The Total Environment 630, 967-976. [Crossref]
2. Jianyong Wu, Laura Jackson. 2016. Association of land use and its change with beach closure in the United States,
2004–2013. Science of The Total Environment 571, 67-76. [Crossref]
3. Wesley Brooks, Steven Corsi, Michael Fienen, Rebecca Carvin. 2016. Predicting recreational water quality advisories:
A comparison of statistical methods. Environmental Modelling & Software 76, 81-94. [Crossref]
4. Qian Zhang, Xia He, Tao Yan. 2015. Differential Decay of Wastewater Bacteria and Change of Microbial Communities
in Beach Sand and Seawater Microcosms. Environmental Science & Technology 49:14, 8531-8540. [Crossref]
5. Charles N. Haas. 2015. Microbial Dose Response Modeling: Past, Present, and Future. Environmental Science &
Technology 49:3, 1245-1259. [Crossref]
6. Qian Zhang, Xia He, Tao Yan. 2015. Impact of indigenous microbiota of subtidal sand on fecal indicator bacteria decay
in beach systems: a microcosm study. Environmental Science: Water Research & Technology 1:3, 306-315. [Crossref]
7. Nicholas Carrara, Katharine Settell, Blake Andrews, David W. Buckalew, Wade A. Znosko. 2015. Expanding the
Indicator Bacteria Concept: A Novel Approach to Assess Ecosystem Risk in Impaired Waters. Journal of Water Resource
and Protection 07:12, 938-955. [Crossref]
8. . Conducting the Dose-Response Assessment 267-321. [Crossref]
9. Adam W. Olivieri, Edmund Seto, Robert C. Cooper, Michael D. Cahn, John Colford, James Crook, Jean-François
Debroux, Robert Mandrell, Trevor Suslow, George Tchobanoglous, Robert A. Hultquist, David P. Spath, Jeffrey
J. Mosher. 2014. Risk-Based Review of California’s Water-Recycling Criteria for Agricultural Irrigation. Journal of
Environmental Engineering 140:6, 04014015. [Crossref]
10. Burcu M. Yavuz, Rachael M. Jones, Stephanie DeFlorio-Barker, Ember Vannoy, Samuel Dorevitch. 2014. Receiver-
Operating Characteristics Analysis: A New Approach to Predicting the Presence of Pathogens in Surface Waters.
Environmental Science & Technology 48:10, 5628-5635. [Crossref]
11. Nathalie Paniel, Julia Baudart. 2013. Colorimetric and electrochemical genosensors for the detection of Escherichia
coli DNA without amplification in seawater. Talanta 115, 133-142. [Crossref]
12. Ronald Wasowski, David Alexander, Steven Kolmes, Nathan Banet, Amy Card, Morgan Haines, Elijah Kolmes, Kelly
Northcutt, Derek Roemer, Sarah Webber. 2013. A Multi-Year Longitudinal Study of Water Quality Parameters in
Four Salmon-Bearing and Recreational Streams on Mount Hood, Oregon. PLoS ONE 8:8, e70453. [Crossref]
13. David M. Gordon. The ecology of Escherichia coli 3-20. [Crossref]
14. Wesley R. Brooks, Michael N. Fienen, Steven R. Corsi. 2013. Partial least squares for efficient models of fecal indicator
bacteria on Great Lakes beaches. Journal of Environmental Management 114, 470-475. [Crossref]
15. E. Chase, J. Hunting, C. Staley, V.J. Harwood. 2012. Microbial source tracking to identify human and ruminant
sources of faecal pollution in an ephemeral Florida river. Journal of Applied Microbiology 113:6, 1396-1406. [Crossref]
16. Gonul Tugrul-Icemer, Aysegul Topaloglu. 2011. Levels of Yeast Mold and Pseudomonas spp . in Antalya Beaches.
Journal of Coastal Research 61, 452-457. [Crossref]
17. A. Korajkic, M.J. Brownell, V.J. Harwood. 2011. Investigation of human sewage pollution and pathogen analysis at
Florida Gulf coast Beaches. Journal of Applied Microbiology 110:1, 174-183. [Crossref]
18. Zachery R. Staley, Jason R. Rohr, Valerie J. Harwood. 2010. The effect of agrochemicals on indicator bacteria densities
in outdoor mesocosms. Environmental Microbiology 12:12, 3150-3158. [Crossref]
19. Fan Feng, Dustin Goto, Tao Yan. 2010. Effects of autochthonous microbial community on the die-off of fecal indicators
in tropical beach sand. FEMS Microbiology Ecology 74:1, 214-225. [Crossref]
20. R.G. Sinclair, E.L. Jones, C.P. Gerba. 2009. Viruses in recreational water-borne disease outbreaks: a review. Journal
of Applied Microbiology 107:6, 1769-1780. [Crossref]
21. A. Korajkic, B.D. Badgley, M.J. Brownell, V.J. Harwood. 2009. Application of microbial source tracking methods in
a Gulf of Mexico field setting. Journal of Applied Microbiology 107:5, 1518-1527. [Crossref]
22. Catherine D. Clark, Warren J. De Bruyn, Joshua G. Jones. 2009. Photochemical production of hydrogen peroxide in
size-fractionated Southern California coastal waters. Chemosphere 76:1, 141-146. [Crossref]
23. Vincent Yau, Timothy J. Wade, Carol K. de Wilde, John M. Colford. 2009. Skin-related symptoms following exposure
to recreational water: a systematic review and meta-analysis. Water Quality, Exposure and Health 1:2, 79-103. [Crossref]
24. D.F. Moore, J.A. Guzman, C. McGee. 2008. Species distribution and antimicrobial resistance of enterococci isolated
from surface and ocean water. Journal of Applied Microbiology 105:4, 1017-1025. [Crossref]
25. Catherine D. Clark, Warren J. De Bruyn, Scott D. Jakubowski, Stanley B. Grant. 2008. Hydrogen peroxide production
in marine bathing waters: Implications for fecal indicator bacteria mortality. Marine Pollution Bulletin 56:3, 397-401.
[Crossref]
26. Michael Beach. Waterborne 335-369. [Crossref]
27. Alyson E. Santoro, Alexandria B. Boehm. 2007. Frequent occurrence of the human-specific Bacteroides fecal marker
at an open coast marine beach: relationship to waves, tides and traditional indicators. Environmental Microbiology 9:8,
2038-2049. [Crossref]
28. Michael J. LaGier, Jack W. Fell, Kelly D. Goodwin. 2007. Electrochemical detection of harmful algae and other
microbial contaminants in coastal waters using hand-held biosensors. Marine Pollution Bulletin 54:6, 757-770.
[Crossref]
29. Iliana B. Baums, Kelly D. Goodwin, Traci Kiesling, David Wanless, Mara R. Diaz, Jack W. Fell. 2007. Luminex
detection of fecal indicators in river samples, marine recreational water, and beach sand. Marine Pollution Bulletin
54:5, 521-536. [Crossref]
30. Ayten Kimiran-Erdem, Elif Ozlem Arslan, Nazmiye Ozlem Sanli Yurudu, Zuhal Zeybek, Nihal Dogruoz, Aysin Cotuk.
2007. Isolation and Identification of Enterococci from Seawater Samples: Assessment of Their Resistance to Antibiotics
and Heavy Metals. Environmental Monitoring and Assessment 125:1-3, 219-228. [Crossref]
31. John M. Colford, Timothy J. Wade, Kenneth C. Schiff, Catherine C. Wright, John F. Griffith, Sukhminder K. Sandhu,
Susan Burns, Mark Sobsey, Greg Lovelace, Stephen B. Weisberg. 2007. Water Quality Indicators and the Risk of
Illness at Beaches With Nonpoint Sources of Fecal Contamination. Epidemiology 18:1, 27-35. [Crossref]
32. Timothy J. Wade, Rebecca L. Calderon, Elizabeth Sams, Michael Beach, Kristen P. Brenner, Ann H. Williams, Alfred
P. Dufour. 2006. Rapidly Measured Indicators of Recreational Water Quality Are Predictive of Swimming-Associated
Gastrointestinal Illness. Environmental Health Perspectives 114:1, 24-28. [Crossref]
33. Michael J. LaGier, Christopher A. Scholin, Jack W. Fell, Joseph Wang, Kelly D. Goodwin. 2005. An electrochemical
RNA hybridization assay for detection of the fecal indicator bacterium Escherichia coli. Marine Pollution Bulletin
50:11, 1251-1261. [Crossref]
34. Ryan H. Dwight, Linda M. Fernandez, Dean B. Baker, Jan C. Semenza, Betty H. Olson. 2005. Estimating the
economic burden from illnesses associated with recreational coastal water pollution—a case study in Orange County,
California. Journal of Environmental Management 76:2, 95-103. [Crossref]
35. Tracie M. Jenkins, Troy M. Scott, Mechelle R. Morgan, Joan B. Rose. 2005. Occurrence of Alternative Fecal Indicators
and Enteric Viruses in Michigan Rivers. Journal of Great Lakes Research 31:1, 22-31. [Crossref]
36. Gabriella Caruso, Renata Denaro, Maria Genovese, Laura Giuliano, Monique Mancuso, Michail Yakimov. 2004. New
methodological strategies for detecting bacterial indicators. Chemistry and Ecology 20:3, 167-181. [Crossref]
37. Timothy J. Wade, Nitika Pai, Joseph N.S. Eisenberg, John M. Colford. 2003. Do U.S. Environmental Protection
Agency Water Quality Guidelines for Recreational Waters Prevent Gastrointestinal Illness? A Systematic Review and
Meta-analysis. Environmental Health Perspectives 111:8, 1102-1109. [Crossref]
38. Fernando S Machado, Susana Mourato. 2002. Evaluating the multiple benefits of marine water quality improvements:
how important are health risk reductions?. Journal of Environmental Management 65:3, 239-250. [Crossref]
39. . Water Quality Criteria . [Crossref]
40. Sarah E. Henrickson, Thomas Wong, Paul Allen, Tim Ford, Paul R. Epstein. 2001. Marine Swimming-Related Illness:
Implications for Monitoring and Environmental Policy. Environmental Health Perspectives 109:7, 645-650. [Crossref]
41. Tony Butler, Mark J. Ferson. 1997. Faecal pollution of ocean swimming pools and stormwater outlets in eastern
Sydney. Australian and New Zealand Journal of Public Health 21:6, 567-571. [Crossref]
42. S J Corbett, G L Rubin, G K Curry, D G Kleinbaum. 1993. The health effects of swimming at Sydney beaches. The
Sydney Beach Users Study Advisory Group. American Journal of Public Health 83:12, 1701-1706. [Abstract] [PDF]
[PDF Plus]
43. Jay M. Fleisher. 1990. Conducting recreational water quality surveys: Some problems and suggested remedies. Marine
Pollution Bulletin 21:12, 562-567. [Crossref]
44. Günay Kocasoy. 1989. The relationship between coastal tourism, sea pollution and public health: A case study from
Turkey. The Environmentalist 9:4, 245-251. [Crossref]
45. C S Sullivan, M E Barron. 1989. Acute illnesses among Los Angeles County lifeguards according to worksite exposures.
American Journal of Public Health 79:11, 1561-1563. [Abstract] [PDF] [PDF Plus]
46. F J Sorvillo, L Lieb, L Mascola, S H Waterman. 1989. Declining rates of amebiasis in Los Angeles County: a sentinel
for decreasing acquired immunodeficiency syndrome (AIDS) incidence?. American Journal of Public Health 79:11,
1563-1564. [Abstract] [PDF] [PDF Plus]
47. R. Morris, I. Cox. VIROLOGICAL QUALITY OF BATHING WATERS IN ENGLAND 337-343. [Crossref]
48. H. Merrett, C. Pattinson, C. Stackhouse, S. Cameron. THE INCIDENCE OF ENTEROVIRUSES AROUND THE
WELSH COAST — A THREE YEAR INTENSIVE SURVEY 345-351. [Crossref]
49. Ora Hadas. 1988. Pathogenic indicators in lake kinneret, Israel. Toxicity Assessment 3:5, 631-641. [Crossref]
50. Joan B. Rose, Rebecca L. Mullinax, Shri N. Singh, Marylynn V. Yates, Charles P. Gerba. 1987. Occurrence of
rotaviruses and enteroviruses in recreational waters of Oak Creek, Arizona. Water Research 21:11, 1375-1381.
[Crossref]
51. A. Margolin, M. Bitrick, R. DeLeon, C. Gerba. Application of Gene Probes to Poliovirus and Hepatitis A Virus
Detection in Water and Shellfish 1746-1751. [Crossref]
52. Allen N. Hagler, Leda C. Mendonça-Hagler, Edielson A. Santos, Sheila Farage, Julio B. Silva Filho, Augusto Schrank,
Renilson B. De Oliverira. 1986. Microbial pollution indicators in Brazilian tropical and subtropical marine surface
waters. Science of The Total Environment 58:1-2, 151-160. [Crossref]
53. Charles N. Haas, Neil J. Hutzler. 1986. Wastewater disinfection and infectious disease risks. Critical Reviews in
Environmental Control 17:1, 1-20. [Crossref]
54. M S Favero. 1985. Microbiologic indicators of health risks associated with swimming. American Journal of Public
Health 75:9, 1051-1054. [Citation] [PDF] [PDF Plus]
55. P L Seyfried, R S Tobin, N E Brown, P F Ness. 1985. A prospective study of swimming-related illness. I. Swimming-
associated health risk. American Journal of Public Health 75:9, 1068-1070. [Abstract] [PDF] [PDF Plus]
56. P L Seyfried, R S Tobin, N E Brown, P F Ness. 1985. A prospective study of swimming-related illness. II. Morbidity
and the microbiological quality of water. American Journal of Public Health 75:9, 1071-1075. [Abstract] [PDF] [PDF
Plus]
57. Jay M. Fleisher. 1985. Implications of coliform variability in the assessment of the sanitary quality of recreational
waters. Journal of Hygiene 94:02, 193-200. [Crossref]
58. C. Jones, A. Goodman, T. Cox, S. Friedman, S. Schultz. Scuba diving in polluted coastal waters 959-961. [Crossref]
59. Sagar M. Goyal, Michael D. Nelson. 1984. Viral pollution of the marine environment. Critical Reviews in
Environmental Control 14:1, 1-32. [Crossref]
60. STANLEY H. LORBER. Gastrointestinal Disorders and Exercise 279-290. [Crossref]
61. V. Cabelli, D. Pedersen. The Movement of Sewage Sludge From the New York Bight Dumpsite as Seen From
Clostridium Perfringens Spore Densities 995-999. [Crossref]
62. V. Cabelli. Predicted Swimming-Associated Gastroenteritis at New York Bight Bathing Beaches 1000-1004. [Crossref]
63. B H Keswick, C P Gerba, S M Goyal. 1981. Occurrence of enteroviruses in community swimming pools. American
Journal of Public Health 71:9, 1026-1030. [Abstract] [PDF] [PDF Plus]
64. G R Brenniman, S H Rosenberg, R L Northrop. 1981. Microbial sampling variables and recreational water quality
standards. American Journal of Public Health 71:3, 283-289. [Abstract] [PDF] [PDF Plus]
65. M. Butler. Virus Removal by Disinfection of Effluents 145-164. [Crossref]
66. V.J. Cabelli. Epidemiology of Enteric Viral Infections 291-304. [Crossref]
67. R.K. DART, R.J. STRETTON. SEWAGE TREATMENT 118-157. [Crossref]
68. C P Gerba, S M Goyal, R L LaBelle, I Cech, G F Bodgan. 1979. Failure of indicator bacteria to reflect the occurrence
of enteroviruses in marine waters. American Journal of Public Health 69:11, 1116-1119. [Abstract] [PDF] [PDF Plus]
69. Tony Butler, Mark J. Ferson. 1977. Faecal pollution of ocean swimming pools and stormwater outlets in eastern
Sydney. Australian and New Zealand Journal of Public Health 21:6, 567-571. [Crossref]