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Similar to NEEAR, no statistically significant associations were observed among CHEERS water recreators swallowing water and having body wetness compared to water recreators with no water contact for all semi-continuous severity outcomes using the ZINB model (Table 5). In addition, semi-continuous measures of severity were not associated with exposures to fecal indicator microbes, when dichotomized at the 75th percentile or when assessed as quartiles (Supplementary Table S3, available with the online version of this paper). However, greater water exposure among CHEERS participants (swallowing water or body wetness vs. water recreators with no water contact) was associated with an increased odds of reporting major responses to symptoms (OR = 1.50 (95% CI: 0.98, 2.30) and OR = 1.29 (95% CI: 1.06, 1.57), respectively). However, when dichotomized at the 75th percentile, concentrations of fecal microbes were not associated with major responses to symptoms among CHEERS participants. When assessing the relationship between quartiles of F+ coliphage and major responses to illness, we observed a significant association between quartile 2 compared to quartile 1. However, this association was not observed in comparisons of response to illness among participants who recreated in water with F+ coliphage concentrations above the median (Supplementary Table S3).

Table 5

Relationship between symptom severity and water exposure or water quality among CHEERS water recreators

Severity outcomeExposureZINBLogistic regression
Ratioa (95% CI)Odds ratiob (95% CI)
Duration of GI symptoms 
n = 6,975 Water ingested vs. no water contact 1.20 (0.59, 2.41) – 
Body wetness vs. no water contact 1.16 (0.79, 1.68) – 
n = 4,693 F+ coliphage, 75th percentile 1.04 (0.64, 1.64) – 
n = 3,854 Enterococci culture, 75th percentile 0.83 (0.51, 1.34) – 
GI SDs 
n = 6,975 Water ingested vs. no water contact 1.03 (0.62, 1.72) – 
Body wetness vs. no water contact 1.09 (0.84, 1.45) – 
n = 4,693 F+ coliphage, 75th percentile 1.15 (0.83, 1.59) – 
n = 3,854 Enterococci culture, 75th percentile 1.00 (0.70, 1.44) – 
Total SDsc 
n = 7,129 Water ingested vs. no water contact 1.19 (0.76, 1.87) – 
Body wetness vs. no water contact 1.24 (0.96, 1.60) – 
n = 4,687 F+ coliphage, 75th percentile 1.11 (0.81, 1.52) – 
n = 3,854 Enterococci culture, 75th percentile 1.02 (0.72, 1.46) – 
Major vs. minor responses to symptomsd 
n = 7,304 Water ingested vs. no water contact – 1.50 (0.98, 2.30) 
Body wetness vs. no water contact – 1.29 (1.06, 1.57) 
n = 4,929 F+ coliphage, 75th percentile – 0.85 (0.67, 1.07) 
n = 4,094 Enterococci culture, 75th percentile – 0.95 (0.74, 1.22) 
Severity outcomeExposureZINBLogistic regression
Ratioa (95% CI)Odds ratiob (95% CI)
Duration of GI symptoms 
n = 6,975 Water ingested vs. no water contact 1.20 (0.59, 2.41) – 
Body wetness vs. no water contact 1.16 (0.79, 1.68) – 
n = 4,693 F+ coliphage, 75th percentile 1.04 (0.64, 1.64) – 
n = 3,854 Enterococci culture, 75th percentile 0.83 (0.51, 1.34) – 
GI SDs 
n = 6,975 Water ingested vs. no water contact 1.03 (0.62, 1.72) – 
Body wetness vs. no water contact 1.09 (0.84, 1.45) – 
n = 4,693 F+ coliphage, 75th percentile 1.15 (0.83, 1.59) – 
n = 3,854 Enterococci culture, 75th percentile 1.00 (0.70, 1.44) – 
Total SDsc 
n = 7,129 Water ingested vs. no water contact 1.19 (0.76, 1.87) – 
Body wetness vs. no water contact 1.24 (0.96, 1.60) – 
n = 4,687 F+ coliphage, 75th percentile 1.11 (0.81, 1.52) – 
n = 3,854 Enterococci culture, 75th percentile 1.02 (0.72, 1.46) – 
Major vs. minor responses to symptomsd 
n = 7,304 Water ingested vs. no water contact – 1.50 (0.98, 2.30) 
Body wetness vs. no water contact – 1.29 (1.06, 1.57) 
n = 4,929 F+ coliphage, 75th percentile – 0.85 (0.67, 1.07) 
n = 4,094 Enterococci culture, 75th percentile – 0.95 (0.74, 1.22) 

aRatio refers to the duration ratio or SDs ratio calculated using ZINB.

bOdds ratio evaluating odds of severe illness in exposed versus the unexposed (reference group).

cIncludes GI and non-GI symptoms.

dED or hospitalization, contact with HCP, take prescription, lost work or daily activities vs. OTC use only or no response.

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