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theHealth 2013; 4(2): 24-29

Review Article

Epidemiological barriers applicable to aquatic therapy pool

Guedes AS
Federal University of Par, Brazil
Correspondence Aureliano da Silva Guedes Federal University of Par. Tray Lomas Valentina, 1412 ap. 1704, Code Post 66.087440 Belm-PA, Brazil E-mail: aurelianoguedes@portugalmail .pt Keywords: Epidemiological Barriers, Therapeutic Pool, Prevention and Control Risks, Waterborne Diseases, Aquatic Physical Therapy Funding None Declared Competing Interest None Received: April 22, 2013 Accepted: June 20, 2013

Exposure to contaminants during bathing or swimming in the pool may lead to the development of clinical conditions. However, the therapeutic pools need special care so as to avoid physical, biological, chemical, and mechanical risks, both for safety of the healthcare professionals as well as patients. Therapeutic pools are often used by the elderly, post-surgical patients, patients who have experienced an orthopedic injury, immune-compromised patients, etc. Keeping in view the importance of aquatic therapy, this article emphasizes on the pathologies which, patient may develop during the treatment and introduces measures for the prevention and control of risks involved. Introduction Since the prehistory man has always sought to live where water was plentiful. The reports indicate that among others, Egypt, Rome, Greece, Mesopotamia, and India were the places where, man began to use water for household activities and medical purposes, Given this, it can be stated that therapies that use water are ancient and today they are present in advance form. Physical therapist who works with aquatic therapy now uses new techniques and methods to have optimum benefit of the technique. Examples of controlled parameters include temperature for a given pathology, effects of density, ebb and flow of therapeutic exercise. The therapist also needs to know the risks related to physical, biological, chemical, and mechanical hazards. The knowledge of microorganisms, their ways of transmission and prevention methods is fundamental to the physiotherapist, especially for aquatic therapy. To counter the risks related with this technique, biosecurity applied to therapeutic pools is a way to prevent possible diseases resulting from improper use and inadequate maintenance to ensure safety and quality of life to the physiotherapist and quality of patient care. This article deals only biosafety rules specific to the therapeutic pools of basic form permeated by the vision of epidemiology of infection control at the hospital. It is noteworthy that, in some cases, these rules are different from those applied to other activities of the physiotherapist. The author's aim was to identify and discuss the risks to health professionals and patients caused by various hazards as mentioned above with greater emphasis on the etiology and pathology, and present solutions epidemiologic to attenuate or eradicate the disease risks associated with the use of these pools. Risks associated with aquatic therapy Therapeutic pool The pools can be made in various materials, for example, concrete, with or without coating, acrylic, fiberglass, etc. with different possible sources of supply and with various functions including recreational, sports, therapeutic, and mixed. Such kind of functions can be observed in water therapy pools of fresh and saltwater. Besides limiting the risks and integrated functions in the therapy pool, the design of the pool must ensure biosafety. There should be one way flow of water from the pool to the drain. If it is not possible to maintain one way flow of water in absolute manner, it should be fairly limited, at the minimum In many other countries including Brazil, many pools used for therapies are also attended by healthy users making it difficult in some cases to provide patient care with proper biosecurity. The source of water in the pool should be well observed and maintained. It is of the public network and quite often, an underground source. Very often, to lower the cost of using the pool, some institutions use underground sources of water. If this is the case, attention should be higher because the risk of contamination of the water is higher, therefore, requires technical certificates issued by a geologist qualified in hydrology. Monitoring of the water quality should be more inten-

ISSN (print): 2218-3299 ISSN (online): 2219-8083

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nse, if any septic tank, gas station, plantations that use large amounts of agrotoxics, waste dumps, industries, cemeteries or any other pollution risks to water is present in the proximity. There are pools that use water currents from rivers, streams, and lakes however, in such cases, some do not use filtration, chlorination, and other chemical control, and hence there are risks of contamination, seen from the origin of the source. An indication that the pool does not receive basic care is the greenish color and/or turbidity, presence of foam, dirt in the edges and slippery floor. These characteristics possibly results from problems with the filtration, little or no chlorination, pH < 7.2 or > 7.6, and lack of general cleaning and maintenance. Treatment of water from the pool used for aquatic therapy should observe proper filtering and cubage, limited number of users, cleaning the bottom blade and surface, strainers (skimmers), and edges of the filter, adding chlorine mode of which can be gaseous or hypochloridric by electrolysis of the salt, and/or adding another chemical with the same function, fungicidal and the control by the periodic testing, thus ensuring quality of the water and consequently treatment of the patient avoiding the risk of occupational diseases for the physiotherapist. The filter maintenance and washing, backwash, rinse to waste reduction that escaped the backwash must follow the protocol(s) relating to cubage and number of users, while also taking into consideration the air pollutants near pool to ensure good filtration, drainage after decanting, and efficient recirculation of the maintenance products. Depending upon the case, it might be necessary to add ultraviolet light C (UV-C), ionization, ozonization, addition of bromine, heating, algaecides, and fungicides to guarantee more water quality and hence the safety of the patient and physiotherapist. For the control of the pool water, it must be subjected to the identification tests of pH, algae (e.g. Selenastrum species) and fungi (e.g. Trichophyton mentagrophytes), among others. The amount of chlorine must be carefully controlled, because in quantity less than required does not reach its object and in excess can cause eye irritation, skin and respiratory problems. Treatment with chlorine however, does not let water free from all problems, as many organisms are chlorine resistant. Hence, there is a need to add other chemical substances for water treatment especially fungicides and algaecides. It is noteworthy that the pools of saltwater initiated in Australia has special care needs including the constant monitoring of pH which tends to be high, requiring stabilizers. Beyond that, all equipment must be anticorrosive. Even in lesser amount, chloride (CI2) is used in salt water pools, so the chlorine generator, through the electrolysis, must be properly maintained to a good stabilization, since will do the transformation of the salt in chlorine. The addition of algaecide in saltwater pools should be observed because there is possibility of emergence of black algae, among other. Therefore, in addition to the care cited throughout this article, there must be other special concerns.

The algaecides and fungicides should follow national and international regulations as well as specific tests, such as the specific amount for per cubic meter of water. The algaecides and fungicides most widely used in pools are dichloroisocyanuric acid (C3Cl2N3NaO3) and trichloroisocyanuric acid (C3Cl3N3O3) and its salts of sodium and potassium, calcium hypochlorite Ca(ClO)2, lithium hypochlorite (LiClO), sodium hypochlorite (NaClO), copper sulfate (CuSO4), quaternaries ammonium, and other. However, in specific cases others can be used including for replacing the CI2, when pool users exhibit some sensitivity to these products. All equipment to be used in the pool and its area should be cleaned, disinfected and properly stored depending upon the type of material, be they banks, cervical buoys, toys, wheelchairs, belts and vests flotation mattresses, cuff sizes, stairs or steps, elastic bands, dumbbells for pool, stretchers, planks and others. Chemical agents Chemical risks are caused by dust, fumes, gases, mists, fog, steam, substances composed of chemicals in general, each with its risks and precautions. The penetration in the human body can be by airway, gastric and dermal.1 Among the diseases caused by chemical hazards in the swimming pools, one can cite asthma (ICD10: J45), dermatitis caused by improper use of chlorine, fungicides, algaecides (ICD10: L24.5), since they must be applied strictly following the recommendations of the amount, cubing, time, action for subsequent use of the pool. Some people, however, show some sensitivity to these products and it should be carefully noted to replace them by others of equal efficiency or other method of water treatment, such as physical treatment. It is important to remember that asbestos should not be used in the roof, because by do so one may put patient at risk causing a type of pneumoconiosis (ICD 10: J61) called asbestosis, causing problems in the pleural plaque (ICD10: J92 .0), and neoplasia. Physical agents Physical risks are those caused by noise, vibration, ionizing radiation (X-ray, gamma ray, manipulation of Cesium 137, etc.), non-ionizing radiation, cold, heat, abnormal pressures, and humidity. Each type of radiation has its degree of tolerability by humans, who rely on the professional distance from the emitting source, age, duration of exposure, exposure tolerability tables that are established. The use of appropriate Personal Protective Equipment (PPE) and Collective Protection Equipment (CPE) for mitigates these risks or exterminate.2 As for radiation, if the pool is not covered, the physiotherapist and patients should use sunscreen suitable for the skin type and avoid using the pool when solar radiation is intense to avoid photodermatitis (ICD 10: L56.8). Use of sunglasses with ultraviolet A (UVA) and ultraviolet B (UVB) protection is also needed to avoid presenile cataract (ICD 10: H26.0) or
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other pathologies. Pools tend to be noisy places, where activities occur inevitably, laughter, screams and dives. During the planning and construction of a swimming pool, acoustic materials should be used for the walls and ceiling of the pool area. They help to avoid excessive noise, which can produce anxiety and stress in children and adults, and do it easier for the therapist, especially when conducting group sessions.3 It is emphasized that these measures also reduce the stress of work during working hours as well as prevent or attenuate the possibility of the involvement of auditory disorders. Use of earplugs in the water, however, can be effective for this problem, both for the therapist and for the patient. The cold is another problem for professionals as some occupational dermatosis is caused by cold, such as erythema pernio, Raynauds phenomenon, frostbite and cold urticaria.4 In case of heated pools, temperature control is of much concern, preferably with suitable thermometers to prevent burns (ICD 10: T29-30). Some appliances for heating pools come with thermometers. However, there is always the need for testing and maintenance to ensure quality operation. Biological risks Biological risks are caused by synanthropic organisms, parasites, fungi, algae, bacteria, and viruses. Risk can occur by direct or indirect contact between therapist and patient, infected animals that are near the pool, among others. Examples of diseases which may develop as a result of direct contact between the therapist and the patient include cholera (ICD 10: A00), conductivities (ICD 10: H10), scabies (ICD 10: B86) caused by Sarcoptes scabiei acarid, HAV (ICD 10: A00), pediculosis (ICD10: B85.2), pyogenic agents. In these cases, the observation of the physical therapist is critical because some pyodermitis (ICD 10: L08.0) that the patient presents are visible, among other diseases, and that same as the professional cannot diagnose, may indicate that the patient should consult the relevant specialist physician. Indirect contact can emphasize HAV, helminthes infections (ICD 10: B75-B83) and other parasites as cryptosporidiosis and microsporidiosis (ICD 10: B60.8). The synanthropic are of concern if they are near or in the pool, for example, the rat is capable of transmitting Haverhill fever (ICD 10: A25.1), Hantavirus, leptospirosis (ICD 10: A27), plague (ICD 10: A20 .9), sodoku (ICD 10: A25.0). The Hantavirus (Hantaan) can be transmitted by feces from infected rodents such as the Bolomys lasiurus reservoir the Araraquara virus, Oligoryzomys nigripes reservoir of the Juquitiba virus (of epidemiological importance in Brazilian) beyond Apodemus agrarius, Peromyscus maniculatus and Oligoryzomys longicaudatus. The leptospirosis is transmitted mainly by the bacterium Leptospira interrogan and its various serotypes which may be present in urine, stool, and saliva of the rodent for example, the rats of the species Rattus norvegicus, Rattus rattus, etc. The rats and other animals can carry Tunga penerans, flea species which can infest humans, in this case, zooparasites dermatosis
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will be named tungiasis (ICD 10: B88.1). Another disease that is transmitted by rodents is the rat-bit-fever. According to Serra (2010, v.2, p. 1381) rat-bit-fever is a disease caused by gram-negative, present in oral flora of rats and other rodents. Are two agents: the most common is the Streptobacillus moniliformes bacillus, which causes 'of Haverhill fever' or 'joint erythema epidemic', and, rarer, is the Spirillum minor, causing Sodoku.5 These and other infectious pathology can be transmitted by these rodents, by direct or indirect exposure to their secretions, hence the need periodic control of pest in the pool area, keeping waste tightly wrapped and by doing correctly chlorination. The presence of animals near the pool, mammals or even mosquitoes risks and can contaminate water puddles or even the pool by gram-negative, such as coccobacillus Francisela tularensis causing tularemia (ICD 10: A21), a pathology that can cause lymphadenopathy, oropharyngeal disorders, oculogranuler, pneumonia, fevers, septicemia, etc. The presence of mosquitoes, depending on the species may be capable of transmitting diseases, for example Aedes aegypti and Aedes albopicus can transmit Flavivirus serotypes I, II, III and IV causing dengue (ICD10: A90), the transmitters may be around the environment in wells, ponds, and even in the pool. It is worth remembering that water is not the transmitter but the mosquitoes are. Yellow fever (ICD10: A95) also Flavivirus transmitted by the species amarlicus viruses are present in digestive system of Aedes aegypti in urban and rural or agricultural settings by Haemagogus. In case of local endemic of the Anopheles, untreated and with inadequate preparation, the water supply to the swimming pool, for example, a water tank or water box, may pose a risk of malaria (ICD10: B50B54). By concomitance, can cite some mammals, including the rat and the dog, which can carry protozoa of the genus Leishimania upon being bitten by flebotomdeos mosquitoes of the species Lutzomyia longipalpis (mosquitoes birigui, straw and other popular names) it is can be transmitted to human, in form of the leishmaniasis cutaneous (ICD10: B55.1) and/or visceral (ICD10: B55.0), therefore, it is necessary to take necessary measures for rodent and pest control, and kill larvae in foci near the pool. There are several microorganisms that are resistant to chlorine, for example, Cryptosporidium sp., Giardia lamblia, G.intestinalis, Microsporidia. In the 1990s, Cryptosporidium species emerged as an important agent of transmission of fluid. Oocysts were found in 80 to 97% of waters of rivers, lakes, ponds and about 50% of affluent water treatment systems have been reported also associated with outbreaks of water pools. The most common form of transmission of Cryptosporidium is transmitted by water, both surface water and treated, however, the treatment of sewage usually not kill the parasite. The oocysts persist in water for more than 140 days and are resistant to chlorine used to disinfect water for human consumption". 6 As to Microspordia, in environment, microspordios are ubiquitous and dispense the form of spores and small oval resistant to conventional treatments of water and thus are pote-

Epidemiological barriers of aquatic therapy pools

ntial pathogens of hydric transmission. Spores of E. bieneusis also been detected in the environmental samples, such as superficial waters, pools, lakes, rivers, sewers and estuaries. E. intestinalis and E. hellem have been detected in water and sewerage.6 The free-living amoebae with emphasis on Naegleria fowleri, are the potential cause of primary amoebic meningoencephalitis. According to Foronda (2009: V.2, p.1612) in his epidemiological description of the free-living amoebae these would "widely dispersed in the environment, particularly in heated pools". The resistance to chlorine and other disinfectants pools are characteristic worthy of registry, only high doses of chlorine are able to kill amoebae in the form trophozoite, being that the cysts are even more resistant. It is necessary, however, be signalize that recently has been used to successfully, a drug for the treatment of keratitis by acanthamoeba, the polyhexamethylene biguanide, previously known only as a disinfectant for pool.7 Numerous microorganisms are resistant to chlorine and some even resistant to the combination of chlorine and UV light, such as Giardia lamblia. However, the commitment of physiotherapist with biosecurity is that he shall control the quality of the water and guide professionals and patients. Clinical manifestations that may occur at therapeutic pools are mainly dermatologic, gastrointestinal, ophthalmic, etc. Presence of microorganisms affects the physiology and may cause diarrhea, abdominal pain, emesis, gastroenteritis. Accidental ingestion of droplets of the pool water is a major cause of parasitic gastritis (ICD 10: K29.7). The etiologic agents must be confirmed by specific laboratory tests. Risks of developing cholera (ICD 10: A00.9), cryptosporidiosis, Escherichia coli, giardiasis (ICD 10: A07.1), trichiuriase are also present but can be avoided. Special attention should be given to the toxigenic Escherichia coli, enterohaemorrhagic, entero-invasive causing serious gastrointestinal infections even involving kidneys. Exogenous character of the organisms may also affect the pools with insufficient chlorination even after evacuation. To determine potential risks, analysis of feces should be done for fecal coliform screening. Regardless of age or clinical condition, use of disposable diaper for pediatric or geriatric even with latex paints is not recommended to patients who will use the therapy pool. The professionals should be alert to outbreaks of diarrheagenic Escherichia coli and emphasizing the enterohaemorrhagic Escherichia coli or other forms of manifestations beyond the normal measures of hygienic maintenance of the pool. Recommended actions by the government should be taken to address the outbreaks of this enterobacteria. Legionellosis may be caused by pathogens Legionella pneumophila leading to community-acquired pneumonia, an important factor of the epidemiological alert in the natural water systems, water reservoirs and pool and equipment such as buoys, noodles, etc. Chlorine resistant property of Legionellosis increases the risk of proliferation in the tropical as well as

heated pools. In case of aquatic therapy pool, the risk is even greater because it facilitates the contamination of elderly, immunocompromised, and post-surgical patients. The microorganism can survive a wide range of conditions including temperatures between 0 and 63C, pH 5.0 to 8.5, and usual chlorination of reservoirs. Proliferation occurs preferably at temperatures between 30 and 50C. Legionella adheres to various materials commonly found in water reservoirs such as rubber, wood, plastics, and organic and inorganic sediments while, presence of other microorganisms and their multiplication further stimulate its proliferation.8 Yoder et al. (1998, V. 57, N.SS09, p.9-10) referring to the contamination by legionella in pools in the United States quotes that, eight outbreaks caused by Legionella were associated with treated recreational water venues during 2005-2006, causing 124 cases of legionellosis (i.e., LD and PF) and resulted in three deaths. The largest of these outbreaks was linked to a spa at an Illinois hotel and involved 43 persons, including three cases of LD resulting in one death. The environmental investigation documented inadequate disinfection in the spa and isolated both L. pneumophila and L. maceachernii from the spa water.9 Humidity pave path for fungal infections for example C. albicans (ICD10: B37) exist in the microbiota of healthy individuals however, continuous exposure to moisture can proliferate causing an imbalance or acquire exogenously especially in elderly and immunocompromised patients who use heated pools. Dermatological risks exist by direct and indirect contact for the patient and physiotherapist, however, as the physiotherapist is longer in the pool and/or on its edge, the humidity concomitantly with etiological agents as Pseudomonas dermatitis or streptococcus located at the therapy pools can cause, for example, folliculitis associated with use of pool. By direct contact patient and therapist, there are risks of scabies (ICD10: I73.8), phthiriasis pubis, herpes simplex (HSV), impetigo by staphylococcus or streptococcus (ICD 10: L01.0), furunculosis (ICD10: L02), Molluscum contagiosum (ICD10: B08.1), and pediculosis (ICD 10: B85.2). The health care professionals should be well instructed as to the risks for the patient and the pool should be well cared to attenuate or mitigate these risks. Physiotherapist with any skin lesions should avoid the pool to avoid any risk to the patient. The humidity, despite being a physical risk, gives concomitance to biological hazards leading to dermatological conditions such as, Paronychia (ICD 10: B37.2, L03.0). Pegas (2009, v3, p.4798) says that these are ... ideal locations for the proliferation of germs, staphylococci and streptococci being the main agents observed in acute cases. In chronic, are encountered others, including Gran-negative, anaerobic, yeasts and even Candida sp.10 Other infection that can cite is by Pseudomonas aeruginosa where the untreated pool is a favorable environment, however, only affecting those who have suffered any injury or have with low immunity. As for folliculitis (ICD 10: L73.9) caused by this microorganisms
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Pegas (2009, v.3, p.4805) affirms that, this type of injury usually occurs in patients contaminated in public pools, pools physiotherapy (whirlpool), baths and other means.10 Other pathologies such as, external otitis, pyoderma, green nail syndrome may be related to humidity caused by long exposure time in these cases and physiotherapist being the one who is spending long time in this environment is at higher risk. In the outdoor facilities, exposure to sun may cause eye problems resulting in photodermatitis. Use of sun block and appropriate glasses can exterminate or reduce these risks. Some problems may occur in the ears, for example, otitis associated with the pool, known as swimmers otitis acute external otitis (ICD 10:H60.3), usually caused by Pseudomonas aeruginosa and Enterobacteriaceae. Warm water in the therapeutic pools favour the growth of these organisms. In case of diabetic patients this problem can evolve and associate with other microorganisms as well and can be avoided with the use of ear plugs during swimming. Rare cases of dermatitis related to accidents in pools resulting in lobomycosis (ICD 10: B48.0) also exists. This pathology requires more comprehensive studies. Allergies with skin erythema may occur by contact with chlorine that affects the skin. It is observed that the physiotherapist, as any health professional, is still subject to various occupational dermatosis by direct or indirect contact. Depending on the type of pathologies of the patients treated in therapeutic pools, special filters may be required that is, multi-barrier filters, type CIO2, POU, P188 ASHRAE this even can prevent up to legionellosis associated with the construction of reservoirs, water tanks. In cases where filters are installed but not properly maintained microorganisms can pass through the pores and become sources of colonies of microorganisms. For example, reduction of filtration capacity or clogging of special filters or ultra-filters can result in the formation of biofilm water quality may also be responsible for it. There are several filters that can be used to hold microorganism capable of retaining them with dimensions of 0.2 to 0.002 known as ultra-filters which are made from various material, for example hollow fiber, cellulose, filter membrane, and others capable of containing microorganisms. It is observed that many therapeutic pools do not have these filters due to unawareness, high cost or short life. Mechanical agents and accidents To mitigate mechanical risks and avoid accidents in the pools, precautions should be taken use of anti-slip coatings, abrasive edges, grouts, handrails, stairs, etc. and their proper periodic maintenance help avoiding lacerations of feet, hands for having friction with damaged materials. If there are wells or similar deep areas discovered, they should be closed with suitable closures to avoid possible falls in them. The pools with various levels of depth should have warning signs for depth, may be marked with coatings in different attractive colour tones or water resistant tapes. The
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pool must have good lighting to facilitate efficient and effective visualization by patient and the therapist of the entire pool area. Campion (2000, p.9) argues that, For the treatment and safety, it is important to take into account the refraction and reflection of the artificial as well as natural light throughout the viewing area of the pool and its depth.3 The depth of the pool should be established in accordance with the type of therapy used and age of the patient, thus avoiding the risk of drowning. The physical therapist should be alert to the use of cranes, aquatic treadmills and other equipment electrical, mechanical or manual to avoid accidents. Such equipment should be used with all necessary care that a patient at the pool deserves and should also be properly maintained. While coming down the stairs or ramp, like any other activity, too, must be closely monitored by the professional. Pools with the heating system powered by the natural gas should be monitored carefully and periodic maintenance should be done for hoses, gaskets, etc. to prevent leakage and consequently risk of explosions. Use of metal hoses and conditioning of the cylinder in a local ventilator is highly recommended. With respect to the gas to be supplied by a central off-site, precautionary measures should be taken to avoid any kind of leakage because leakage as small as from a thread may result in the explosion. Electrical maintenance should also be periodically scheduled. Pools with electric heating equipment must be protected against burns as well as electrical wirings should be well insulated to avoid electric shock in all situations. Protection of wiring and parts that are sensitive to high temperatures must be protected and insulated to prevent explosions, fires, burns (ICD10: T20-T32) and electric shock (ICD10: W87). Preventive maintenance should be performed periodically by competent professionals. The risk of drowning (ICD10: W67.8), cardiopulmonary arrest (ICD10: R09.2), fractures (ICD10: T14.2), among others, same following the rules described above, may occur. The physiotherapist, however, must require first aid equipment near the pool area and have the expertise to use them. Bates & Hanson, (1998, p.29) warn that, physical therapists need to know the proper use and application of all the rescue equipment by the pool area; this includes rescue floating, planks column and other piece of equipment.11 Ethical, social, and professional responsibility lies on the shoulders of the management or owner of the clinic to provide care to avoid occupational hazards and limit the risks of accidents due to multiple factors to the physiotherapist as well as to the patients. Conclusions The basic measures of hygiene are fundamental such as, appropriate treatment and monitoring of water, performing the tests of fungi, algae, pH, taking a shower before and after using the pool, avoid swallowing water during swimming, and do not use water therapies wherever not recommended. It is recommended to follow the guidelines of authentic body for

Epidemiological barriers of aquatic therapy pools

example, CDC or the country in which the therapy is to be performed. Proper sanitization of the equipment such as buoys and floats are among measures of biosecurity. It is necessary to intensify health education measures for staff and patients such as, use measures for the treatment and control of water, hold synanthropic control, use of PPE and EPC and above all, the therapist must understand that surveillance to the risks cited here is of great importance for the clinical condition of their patients. Use of pool should be specific, because by virtue of their characteristics, pools designed for sports and recreational are not recommended for therapeutic purposes. However, in the absence of exclusive pools for therapeutic purposes, biosecurity problems become more complicated, because they increase the risk to patients. Epidemiologists should continue research focusing on the therapeutic pools to identify any risks, be they: physical, chemical, mechanical or biological, and create epidemiological barriers to eliminate or reduce such etiological agents. References:
1. GUEDES, Aureliano da Silva. Biossegurana e a responsabilidade do fisioterapeuta. In: GUEDES, Aureliano da Silva, GONALVES, Reinaldo Williams de Almeida. Textos em Fisioterapia. Belm: Aureliano da Silva Guedes editor; Editora ESAMAZ, 2011. p. 11- 28. ISBN 978-85-911681-1-8. 2. GUEDES, Aureliano da Silva. Noes de Biossegurana para Assistentes Sociais que Atuam em Instituies Psiquitricas, Hospitais e Assemelhados. In: Revista Cientfica ESAMAZ. Belm. V.1, n.1 jul./dez., 2009. p. 8-21. ISSN 2176-3062.

3. Campion MR. Hidroterapia: princpios e prtica. So Paulo: Manole, 2000.p.9. ISBN 85-204-0983-0 4. Pires MC, Rodrigues RN dos Santos. Dermatoses Ocupacionais. In: LOPES, Antonio Carlos. Tratado de Clnica Mdica. (2nd edition). So Paulo : Roca, 2009. V.3, p.4924-4929. ISBN 978-85-7241-779-2. 5. Serra FB. Febre por Mordedura de Rato. In: VERONESI, Ricardo. Tratado de Infectologia. (4th edition, revised and expanded). So Paulo : Atheneu, 2010.V. 2, p.1381-1382. ISBN 978-85-388-0101-6. 6. Silva RM, Almeida TTC. Criptosporidose e Microsporidose. In: VERONESI, Ricardo. Tratado de Infectologia. (4th edition, revised and expanded). So Paulo : Atheneu, 2010.V. 2, p.1625-1632. ISBN 978-85-388-0101-6. 7. Foronda AS. Infeces por Amebas de Vida Livre. In: VERONESI, Ricardo. Tratado de Infectologia. (4th edition, revised and expanded). So Paulo : Atheneu, 2010.V. 2, p.1612-1620. ISBN 978-85-388-0101-6 8. Godoy CVF, Focaccia R, Cavalhaes CHVF de Godoy, Machado AN de Oliveira. Legionelose. In: VERONESI, Ricardo. Tratado de Infectologia. (4th edition, revised and expanded). So Paulo : Atheneu, 2010.V. 1, p.11271132. ISBN 978-85-388-0101-6. 9. Yoder JS, et al. Surveillance for Waterborne Disease and Outbreaks Associated with Recreational Water Use and Other Aquatic Facility-Associated Health Events. In: Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention (CDC), V.57, N. SS9. P.9-10. Sep. 12, 2008. 10. Pegas, JR. Infeces Bacterianas. In: LOPES, Antonio Carlos. Tratado de Clnica Mdica. (2nd edition). So Paulo: Roca, 2009. V.3, p.4792-4808. ISBN 978-85-7241-779-2. 11. Bates A, Hanson N. Exerccios aquticos teraputicos. So Paulo: Manole, 1998.p.29.

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