Combined Sewer Overflow (CSO) Into Local River, Lake, or Beach After Heavy Rain: Raw Sewage Pathogens, Leptospirosis, and Post-Immersion Decontamination¶

When a summer thunderstorm, tropical downpour, or rapid snowmelt dumps more than 1.5 to 2.5 centimeters (0.6 to 1.0 inch) of rain per hour onto an older city served by a Combined Sewer System (CSS), municipal wastewater treatment plants cannot handle the combined surge of street stormwater and household sanitary sewage. To keep raw sewage from backing up into thousands of residential basements and city streets, automatic hydraulic relief weirs (Combined Sewer Overflow [CSO] outfalls) open along urban rivers, rowing canals, harbors, and swimming beaches, discharging millions of liters of untreated human feces, hospital effluent, industrial runoff, and rat-urine-contaminated street water directly into recreational waterways for 24 to 72 hours after the rain stops. If a kayaker, rower, triathlete, surfer, angler, flood-rescue worker, or pet is submerged in a river, lake, or coastal beach during or within 48 hours after a CSO discharge, they face immediate exposure to leptospirosis (Weil's disease), enterotoxigenic Escherichia coli (STEC O157:H7), norovirus, hepatitis A, Cryptosporidium, and Vibrio vulnificus / Aeromonas hydrophila necrotizing soft-tissue infections. Call your local emergency number (911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom) via our emergency numbers directory if anyone develops high fever, jaundice, red-purple skin bullae, or respiratory distress after sewage-water immersion, and consult our sibling guides on sanitary sewer force main rupture, raw sewage geyser in street, and backwater valve closure, sewer main overflow and street flooding, and citywide water main break and boil water.

Surviving accidental immersion or recreational contact with a Combined Sewer Overflow (CSO) or Sanitary Sewer Overflow (SSO) plume requires executing four protocols established by the U.S. Environmental Protection Agency (EPA National CSO Control Policy), the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the UK Health Security Agency (UKHSA): enforcing the mandatory 48-to-72-hour post-rain "No-Swim / No-Capsize" window downstream of urban CSO outfalls, performing a 15-minute head-to-toe warm soap-and-water shower followed by high-pressure irrigation (500 mL potable water or sterile saline plus 2% Chlorhexidine or Povidone-Iodine) of every skin scrape, blister, or leech/insect bite before bacteria invade the dermis, flushing eyes and nasal passages with sterile 0.9% saline without using tap water inside the nose, and requesting targeted post-exposure medical evaluation (Doxycycline 200 mg single-dose leptospirosis prophylaxis, Tdap tetanus booster, and Hepatitis A vaccine/immunoglobulin within 14 days) when high-risk ingestion or open-wound immersion occurs.

Do this now¶

1. Exit the Water Immediately If You See or Smell CSO Outfall Indicators: Brownish-Grey Plumes, Floating "Sewage Litter" (Wet Wipes, Tampon Applicators, Condoms), Surface Foam/Grease Slicks, or Gulls Diving at a Submerged Pipe. Many urban CSO outfalls are submerged below the waterline of rivers, lakes, and beaches and begin discharging within 15 to 30 minutes of a heavy downpour. If a storm hits while you are rowing, kayaking, paddleboarding, or swimming, or if your municipal CSO alert map shows an active or recent discharge (within the past 48 hours), get out of the water immediately, keep your mouth closed so wake spray does not hit your lips, and do not rinse your hands or face in the river.
2. Execute the "First-30-Minute Mucous Membrane & Shower Decontamination" Before Eating, Drinking, or Touching Your Face. Before touching a water bottle, snack, phone, or car steering wheel, sanitize your hands with 60% to 70% alcohol gel (note that alcohol gel kills bacteria like E. coli and Leptospira, but does NOT kill Norovirus or Cryptosporidium oocysts, you must wash with friction and soap). Strip off all wet wetsuits, rash guards, life jackets (PFDs), and water shoes outside or in a plastic trash bag, shower thoroughly with warm potable water and antibacterial soap for at least 5 to 10 minutes, and blow your nose and spit out any saliva rather than swallowing post-nasal drip.
3. Irrigate Every Cut, Rower's Blister, Scrape, or Bug Bite Under High-Pressure Running Water for 5 Full Minutes, Apply Povidone-Iodine or Chlorhexidine, and NEVER Close or Tape a Sewage-Exposed Wound Tightly. Even microscopic skin abrasions (such as rowing oar blisters on the palms, shaved skin on the legs, or bare-foot shell scrapes) serve as direct entry portals for Leptospira spirochetes, Aeromonas hydrophila, and Vibrio vulnificus. Scrub and flush every break in the skin with soap and running potable water (or a 500 mL sterile saline bottle pierced to squirt a pressurized stream), apply 10% Povidone-Iodine (Betadine) or 2% to 4% Chlorhexidine Gluconate (Hibiclens), and cover with a breathable sterile gauze pad (never seal a sewage-contaminated wound with cyanoacrylate liquid skin glue or tight butterfly strips, which traps anaerobic and necrotizing bacteria inside).
4. If River or Beach Sewage Water Splashed Into Your Eyes or Mouth: Flush Eyes with Sterile 0.9% Saline for 5 to 10 Minutes, and Rinse Your Mouth with Antiseptic Mouthwash Without Swallowing. Do not rub sewage-splashed eyes (which grinds silt and Adenovirus / Acanthamoeba into the cornea); irrigate both eyes with sterile saline eyewash. Swish and spit 0.12% Chlorhexidine or alcohol/cetylpyridinium antiseptic mouthwash for 30 seconds to reduce oral mucosal viral and bacterial load.
5. Contact a Physician or Urgent Care Clinic Within 24 Hours If You Swallowed CSO Water or Immersed an Open Wound: Ask About Doxycycline Leptospirosis Prophylaxis, Tdap Tetanus Booster, and Hepatitis A Post-Exposure Prophylaxis. Under CDC / WHO clinical guidance, high-risk freshwater sewage immersion (especially capsizing with water ingestion or open-wound exposure in urban rivers harboring rat urine) warrants consideration of single-dose oral Doxycycline 200 mg post-exposure prophylaxis (PEP) within 24 to 72 hours to prevent leptospirosis, a Tdap / Td tetanus booster if your last shot was more than 5 years ago for a dirty wound, and a single dose of Hepatitis A vaccine (plus IG if immunocompromised) within 14 days if unvaccinated.
6. Watch for the "Two-Phase" Red Flags Over the Next 2 to 30 Days: Rapid Cellulitis (12 to 72 Hours) vs. Leptospirosis / Weil's Disease (5 to 14 Days). Go to a Hospital Emergency Department immediately and explicitly tell the triage doctor "I was submerged in a Combined Sewer Overflow river/beach on [Date]" if you develop (A) Rapidly spreading red/purple skin swelling, severe pain out of proportion to a minor cut, or blood-filled blisters within 12 to 72 hours (Aeromonas or Vibrio necrotizing fasciitis), OR (B) High fever, intense calf/lower-back muscle aches, bloodshot eyes (conjunctival suffusion without pus), yellow eyes/skin (jaundice), dark brown urine, or coughing up blood 2 to 30 days later (Leptospirosis / Weil's disease).

Decision tree: Combined Sewer Overflow (CSO) immersion decontamination & medical triage¶

flowchart TD
    A["Person or Pet Submerged or Splashed in River, Lake, Canal, or Beach During or Within 48-72 Hours After Heavy Rain (CSO / SSO Event)"] --> B{"Immediate Step 1: Decontamination Within 30 Minutes of Exiting Water"}
    B --> C["Strip wet gear outside -> Shower 5-10 min with warm potable water & soap -> Irrigate ALL cuts/blisters with 500 mL pressurized water + Povidone-Iodine / Chlorhexidine -> Flush eyes with sterile 0.9% saline"]
    C --> D{"Did the person swallow sewage-contaminated water, submerge their head, or expose an open cut/blister/rash?"}
    D -->|"YES: Swallowed water, head immersion, or open skin wound"| E["Same-Day Medical / Urgent Care Consult (Within 24-72 hrs): 1. Tdap Tetanus Booster (if >5 yrs since last dose) 2. Discuss Doxycycline 200 mg PO x1 Leptospirosis PEP (freshwater/urban river) 3. Hepatitis A Vaccine PEP (if unvaccinated, within 14 days)"]
    D -->|"NO: Brief splash on intact skin only, promptly washed"| F["Monitor skin and temperature for 30 days; disinfect boat/gear/wetsuit with 0.1% Sodium Hypochlorite (1:50 bleach) or Quaternary Ammonium"]
    E --> G{"Monitor for Acute Clinical Red Flags Over Day 1 to Day 30"}
    F --> G
    G -->|"Hours 12 to 72: Rapidly spreading red/purple skin swelling, severe pain out of proportion to cut, or bullae"| H["EMERGENCY DEPARTMENT IMMEDIATELY: Suspect Aeromonas hydrophila (freshwater) or Vibrio vulnificus (brackish/saltwater) Necrotizing Infection -> IV Ceftriaxone/Cefepime + Doxycycline + Surgical Consult"]
    G -->|"Days 1 to 10: Explosive watery or bloody diarrhea, vomiting, abdominal cramps"| I["GI Pathogen Workup: Oral Rehydration Salts (ORS) -> Stool PCR (STEC O157:H7, Salmonella, Campylobacter, Cryptosporidium, Giardia) -> AVOID antimotility drugs (Loperamide) if bloody diarrhea/fever"]
    G -->|"Days 2 to 30: Sudden high fever, severe calf/back myalgia, red eyes (conjunctival suffusion), jaundice, dark urine, or shortness of breath"| J["EMERGENCY DEPARTMENT IMMEDIATELY: Suspect Leptospirosis / Weil's Disease -> Blood/Urine PCR + MAT Serology, Renal/Hepatic Panel -> Start Doxycycline or IV Ceftriaxone IMMEDIATELY before lab confirmation"]

Part 1: How a Combined Sewer Overflow (CSO) Works & Why the "48-to-72-Hour Post-Rain Rule" Exists¶

Over 700 municipalities in the United States (concentrated in the Northeast, Great Lakes, Midwest, and Pacific Northwest, such as New York City, Chicago, Boston, Philadelphia, Washington D.C., Seattle, Portland, St. Louis, and Indianapolis), as well as major cities across the United Kingdom (London Thames Tideway, Manchester, Glasgow), Canada (Toronto, Montreal, Vancouver), and Europe (Paris Seine, Berlin Spree), rely on 19^th- and early-20^th-century Combined Sewer Systems (CSS).

1. The Hydraulic Physics of a CSO Regulator Weir¶

• Dry Weather Flow: During dry weather, 100 percent of domestic sanitary sewage (toilets, sinks, hospitals, industrial drains) flows through a single pipe to the Wastewater Treatment Plant (WWTP).
• Wet Weather Overflow (> 0.5 to 1.0 inch / 1.3 to 2.5 cm of rain): Because street storm-drain catch basins feed into the exact same underground pipe, a heavy rainstorm increases flow volume 10- to 50-fold within 20 minutes.
• The Relief Weir: To prevent the treatment plant from flooding and stop raw sewage from exploding out of residential toilets, an underground diversion dam (regulator weir or tide gate) spills the excess mixed flow, consisting of raw, unscreened, unchlorinated human sewage mixed with urban street runoff, directly out of riverside or beachfront CSO outfall pipes.
• Sanitary Sewer Overflows (SSOs) in Separate Sewer Cities: Even in newer cities with separate storm and sanitary pipes, heavy rain infiltrates cracked underground sanitary mains (Inflow and Infiltration [I&I]) or knocks out electric sewage lift-station pumps, causing Sanitary Sewer Overflows (SSOs) that bubble out of manholes directly into neighborhood creeks and lakes.

2. Why Is the Water Still Dangerous 24 to 48 Hours After the Sky Clears?¶

Swimmers, triathletes, and rowers frequently make the mistake of entering a river or beach the morning after a heavy thunderstorm because the sun is shining. After a CSO discharge ends, the waterway remains heavily contaminated for 48 to 72 hours (EPA / Public Health Beach Closure Standard) for three reasons: 1. Fecal Coliform & Enterococcus Die-Off Lag: While direct ultraviolet (UV) sunlight in clear water gradually inactivates bacteria, CSO plumes are loaded with suspended silt and organic turbidity (high Nephelometric Turbidity Units [NTU]) that shields bacteria, viruses, and protozoan cysts from UV light. 2. Tidal Estuaries & Slow-Moving Lakes: In tidal rivers (like the Hudson, Potomac, Thames, or Delaware) and enclosed lakes/harbors, the incoming tide pushes the raw sewage plume upstream, sloshing the same fecal mass back and forth past boathouses and beaches for 4 to 6 tidal cycles (48 to 72 hours). 3. Bottom Sediment Resuspension: Enteric viruses (Norovirus, Adenovirus, Hepatitis A) and Cryptosporidium oocysts bind to heavy clay particles that settle into the shallow riverbed or beach sand; when waders, rowers launching shells, or dogs stir up the ankle-deep bottom sediment 2 days later, they resuspend concentrated infectious pathogens.

Part 2: The 6 High-Risk Pathogens in Raw CSO Water (Incubation, Clues & Specific Treatments)¶

When a patient develops illness after CSO or floodwater immersion, clinicians must distinguish among six distinct pathogen classes with vastly different incubation timelines and antimicrobial treatments:

Part 3: Step-by-Step Post-Immersion Decontamination Protocol (Human, Gear, and Pets)¶

1. Human Body Decontamination (The First 30 Minutes)¶

If you capsize a kayak, rowing shell, or sailboat, fall off a dock, or swim in a waterway during a CSO / SSO advisory: 1. Mouth, Nose, and Eyes First (At the Boat Dock or Car): - Spit, Do Not Swallow: Immediately spit out any water in your mouth. Rinse your mouth thoroughly with bottled potable water and spit, then swish 15 to 20 mL of antiseptic mouthwash (0.12% Chlorhexidine or Listerine / cetylpyridinium chloride) for 30 seconds and spit. - Eyes: Flush both eyes with sterile 0.9% sodium chloride eyewash pods (100 to 250 mL per eye) with your head tilted sideways so runoff does not enter the other eye. - Nose: Gently blow your nose into a disposable tissue. If thick river muck entered the nostrils, rinse ONLY with sterile 0.9% saline spray (never squirt unboiled tap water up the nose, due to Naegleria fowleri / Acanthamoeba risk). - Ears ("Swimmer's Ear" Prevention): Tilt your head to each side to drain river water from the ear canals, then instil 4 to 5 drops of a 1:1 mixture of 70% Isopropyl Alcohol and White Vinegar (2% Acetic Acid) into each ear canal (unless you have a perforated eardrum or ear tubes) to kill Pseudomonas aeruginosa and Aeromonas. 2. Strip Gear Into a Sealed Bag & Take a 10-Minute Soap Shower: - Peel off wet clothing, wetsuits, booties, and gloves downwind and away from your face (pull wet rash guards off from the bottom cautiously with eyes and mouth tightly shut, or step into a shower first and rinse the outside of the shirt before pulling it over your head). - Wash your entire body and hair with warm running potable water and liquid soap (or 4% Chlorhexidine Gluconate surgical scrub for the legs, hands, and torso) for at least 5 to 10 minutes. 3. High-Pressure Wound Irrigation & Open-Dressing Care: - Inspect your hands (especially rower's palm blisters), shins, ankles, and feet under bright light. - Flush every cut, blister, or scrape with at least 500 mL of pressurized potable water or sterile saline (use an 18-gauge catheter tip on a 35 mL syringe or poke a pinhole in a sterile water bottle cap to generate 7 to 15 psi irrigation pressure). - Apply 10% Povidone-Iodine solution or 2% Mupirocin / Bacitracin ointment and cover with a loose, breathable sterile gauze dressing. Check the wound every 6 hours for the first 72 hours: if a red border advances outward (draw a pen line around any redness), go to the Emergency Department immediately.

2. Decontaminating Wetsuits, Life Jackets (PFDs), Kayaks, Rowing Shells, and Dogs¶

• Rowing Shells, Kayaks, Oars, and Hard Gear: Never spray down a CSO-contaminated boat with a high-pressure power washer at head height (which aerosolizes Norovirus and STEC E. coli into an inhalable mist that infects everyone in the boathouse bay). Instead, wear nitrile gloves and eye protection, wash the hull and oar handles with detergent and a low-pressure garden hose, and sponge down all grip surfaces with a 0.1% Sodium Hypochlorite (1:50 household bleach dilution: 1/3 cup [80 mL] of 5% to 6% bleach per 1 gallon [3.8 L] of water) or an EPA List N Quaternary Ammonium disinfectant with a 10-minute wet contact time, followed by a freshwater rinse.
• Neoprene Wetsuits, Booties, and PFDs (Where Bleach Damages Fabric): Bleach degrades neoprene and weakens nylon life-jacket webbing. Soak wetsuits and PFDs in a tub of cool water mixed with a phenolic or quaternary ammonium wetsuit/gear sanitizer (such as Steramine or Revivex BCD/Wetsuit Sanitizer) for 15 minutes, rinse thoroughly, and hang in direct outdoor UV sunlight to dry completely.
• Dogs That Swam in or Drank CSO Water: Dogs are extremely susceptible to acute fatal Leptospirosis and Giardia / Campylobacter enteritis (even dogs vaccinated against leptospirosis may not be covered against all urban rat serovars). Wearing waterproof gloves, hose and shampoo the dog outdoors with chlorhexidine pet shampoo (keeping soap out of eyes), dry their paws and belly, prevent them from licking their wet fur, and call your veterinarian immediately to ask about oral Doxycycline / Amoxicillin prophylaxis if the dog drank from the sewage plume.

First aid and infectious-disease instructions on this page are for emergency guidance only and never replace medical evaluation. We recommend taking an accredited First Aid and Water Safety course from the American Red Cross, St John Ambulance, or your national Red Cross or Red Crescent society.

Regional emergency numbers and agency protocols¶

• United States: Call 911 for any medical emergency (such as suspected Weil's disease or necrotizing wound infection). Combined Sewer Overflows (CSOs) and Sanitary Sewer Overflows (SSOs) are regulated by the U.S. Environmental Protection Agency (EPA) under the Clean Water Act (NPDES Permit Program, 1994 CSO Control Policy, and 40 CFR 122.38 Public Notification Rule for the Great Lakes). Recreational beach water quality closures are governed by the EPA BEACH Act Recreational Water Quality Criteria (which trigger a beach advisory when Enterococci exceed a geometric mean of 35 CFU/100 mL or a Statistical Threshold Value [STV] of 130 CFU/100 mL, or E. coli exceeds a geometric mean of 126 CFU/100 mL / STV of 410 CFU/100 mL). Report an unmapped raw sewage spill to your municipal 311 / Water Utility Emergency Line and State Department of Environmental Protection.
• United Kingdom: Call 999 for medical emergencies or NHS 111 for urgent post-immersion medical advice and leptospirosis/tetanus assessment (citing the UK Health Security Agency [UKHSA] / British Rowing Leptospirosis (Weil's Disease) Guidance). To report a raw sewage discharge or fish kill in a river or beach, call the Environment Agency 24-Hour Incident Hotline on 0800 80 70 60 (England), Natural Resources Wales on 0300 065 3000, SEPA on 0800 80 70 60 (Scotland), or NIEA on 0800 80 70 60 (Northern Ireland). Check live storm overflow discharges via the Rivers Trust Sewage Map or Surfers Against Sewage Safer Seas & Rivers Service.
• Canada: Call 911 for emergencies or 811 (HealthLink / Info-Santé / Health811) for 24/7 registered nurse triage after sewage water exposure. Municipal CSO reporting and recreational water closures follow Health Canada's Guidelines for Canadian Recreational Water Quality (E. coli <= 200 CFU/100 mL geometric mean, <= 400 CFU/100 mL single-sample maximum; Enterococci <= 35 CFU/100 mL geometric mean, <= 70 CFU/100 mL single sample) and Environment and Climate Change Canada (ECCC) Wastewater Systems Effluent Regulations.
• European Union: Call 112 for emergency medical care. Coastal and inland swimming waters across EU member states are regulated under the EU Bathing Water Directive (2006/7/EC) and the revised Urban Wastewater Treatment Directive (UWWTD), which mandate short-term pollution advisories during stormwater CSO events based on Intestinal Enterococci and Escherichia coli thresholds.
• Australia and New Zealand: Call 000 (Australia) or 111 (New Zealand) for emergencies. State EPA beach watch programs (such as NSW Beachwatch and EPA Victoria Yarra Watch) and New Zealand's LAWA (Land, Air, Water Aotearoa Can I Swim Here?) enforce the mandatory 48-hour post-heavy-rain "No-Swim" rule under NHMRC Guidelines for Managing Risks in Recreational Water. See our complete directory at emergency numbers.

Frequently asked questions¶

How long after heavy rain is a river, lake, or urban beach unsafe for swimming, kayaking, or rowing due to Combined Sewer Overflows (CSOs)?¶

Public health agencies (including the U.S. EPA, UK Environment Agency, Health Canada, and state Beachwatch programs) advise staying out of urban rivers, lakes, harbors, and coastal beaches near storm or CSO outfalls for at least 48 to 72 hours after heavy rainfall ends. Even when the sun comes out the next morning, suspended silt shields fecal bacteria, Norovirus, and Cryptosporidium from UV light, and tidal currents in estuaries push raw sewage plumes upstream and downstream for 4 to 6 tidal cycles before bacterial counts return to safe levels.

What should I do immediately if I capsize or swallow water in a river during a Combined Sewer Overflow event?¶

Immediately spit out any river water without swallowing, rinse your mouth with bottled potable water, and swish and spit an antiseptic mouthwash (such as 0.12% chlorhexidine or cetylpyridinium chloride) for 30 seconds. Flush your eyes with sterile 0.9% saline, shower with warm potable water and soap for 10 minutes within 30 minutes of leaving the water, and scrub and irrigate every skin cut, scrape, or rower's blister with pressurized clean water and povidone-iodine or chlorhexidine. Contact a doctor within 24 hours to discuss a tetanus booster, Hepatitis A vaccine prophylaxis, and single-dose oral Doxycycline (200 mg) leptospirosis prophylaxis.

What are the early warning signs of Leptospirosis (Weil's Disease) after swimming or rowing in sewage-polluted freshwater?¶

Leptospirosis typically begins 5 to 14 days (range 2 to 30 days) after exposure with a sudden high fever, chills, severe headache, nausea, and two hallmark clues that distinguish it from regular influenza: intense muscle pain localized in the calves and lower back, and conjunctival suffusion (bright red, bloodshot eyes without yellow pus). If untreated, 10 to 15 percent of patients progress to Phase 2 (Weil's disease), marked by yellow jaundice, dark brown or absent urine (acute kidney failure), meningitis, and coughing up blood. Tell your emergency room doctor immediately about your river or sewage-water exposure so they can start Doxycycline or IV Ceftriaxone right away.

Why is an open cut or blister exposed to warm coastal or brackish sewage runoff an immediate emergency if it turns red and painful?¶

Warm brackish, estuarine, and coastal waters contaminated by stormwater and sewage runoff harbor Vibrio vulnificus, while freshwater sewage plumes harbor Aeromonas hydrophila. Both bacteria can invade a tiny skin scrape, oyster cut, or rowing blister and trigger necrotizing fasciitis within 12 to 48 hours. If any wound exposed to river or beach water develops rapidly spreading redness, swelling, fever, purple or blood-filled blisters (bullae), or severe pain out of proportion to the size of the cut, go to a hospital emergency department immediately for intravenous antibiotics and surgical evaluation.

Related guides¶

• Sanitary sewer force main rupture, raw sewage geyser in street, and backwater valve closure
• Sewer main overflow and street flooding
• Citywide water main break and boil water
• Do-not-drink vs. boil-water advisory: chemical or fuel contamination in tap water
• Flash floods

Sources and official guidance¶

• U.S. Environmental Protection Agency (EPA): Combined Sewer Overflows (CSO) Control Policy (59 FR 18688), NPDES Public Notification Requirements for Combined Sewer Overflows to the Great Lakes Basin (40 CFR Part 122), and Recreational Water Quality Criteria (EPA 820-F-12-058: Enterococci & E. coli Thresholds).
• Centers for Disease Control and Prevention (CDC) & World Health Organization (WHO): Leptospirosis Clinical Guidance for Healthcare Providers (Doxycycline 200 mg Post-Exposure Prophylaxis & Weil's Disease Treatment), Vibrio vulnificus & Aeromonas Wound Management in Flood/Sewage Water, and ACIP Post-Exposure Prophylaxis Guidelines for Hepatitis A and Tetanus.
• UK Health Security Agency (UKHSA), Environment Agency (EA), & British Rowing: Leptospirosis (Weil's Disease): Clinical and Recreational Water Safety Guidance for Rowers, Paddlers, and Open-Water Swimmers, and Event Duration Monitoring (EDM) Storm Overflow Reporting Standards.
• Health Canada: Guidelines for Canadian Recreational Water Quality (4^th Edition: Microbiological Pathogens, Combined Sewer Overflow Risk Management, and 48-Hour Post-Rainfall Advisories).
• Infectious Diseases Society of America (IDSA): Clinical Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections (Aquatic Wound Infections: Aeromonas hydrophila, Vibrio vulnificus, and Mycobacterium marinum) and Infectious Diarrhea (STEC O157:H7 Antimotility Contraindications).