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Open Access Research article

Equivalency of risk for a modified health endpoint: a case from recreational water epidemiology studies

Larry J Wymer1*, Timothy J Wade2 and Alfred P Dufour1

Author Affiliations

1 United States Environmental Protection Agency, National Exposure Research Laboratory, 26 W. Martin Luther King Drive, Cincinnati, OH 45268, USA

2 United States Environmental Protection Agency, National Health Effects Research Laboratory, 109 T.W. Alexander Drive, Research Triangle Park, NC 27709, USA

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BMC Public Health 2013, 13:459  doi:10.1186/1471-2458-13-459

Published: 10 May 2013



The United States Environmental Protection Agency (USEPA) and its predecessors have conducted three distinct series of epidemiological studies beginning in 1948 on the relationship between bathing water quality and swimmers’ illnesses. Keeping pace with advances in microbial technologies, these studies differed in their respective microbial indicators of water quality. Another difference, however, has been their specific health endpoints. The latest round of studies, the National Epidemiological Assessment of Recreational (NEEAR) Water studies initiated in 2002, used a case definition, termed “NEEAR GI illness” (NGI), for gastrointestinal illness corresponding closely to classifications employed by contemporary researchers, and to that proposed by the World Health Organization. NGI differed from the previous definition of “highly credible gastrointestinal illness” (HCGI) upon which the USEPA’s 1986 bathing water criteria had been based, primarily by excluding fever as a prerequisite.


Incidence of NGI from the NEEAR studies was compared to that of HCGI from earlier studies. Markov chain Monte Carlo method was used to estimate the respective beta binomial probability densities for NGI and HCGI establish credible intervals for the risk ratio of NGI to HCGI.


The ratio of NGI risk to that of HCGI is estimated to be 4.5 with a credible interval 3.2 to 7.7.


A risk level of 8 HCGI illnesses per 1000 swimmers, as in the 1986 freshwater criteria, would correspond to 36 NGI illnesses per 1000 swimmers. Given a microbial DNA-based (qPCR) water quality vs. risk relationship developed from the NEEAR studies, 36 NGI per 1000 corresponds to a geometric mean of 475 qPCR cell-equivalents per 100 ml.

Recreational water quality; Swimming-related illness; Gastrointestinal illness; Epidemiological study