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Parasites

Sinus Rinsing For Health or Religious Practice

woman using neti pot

Neti pots look like little teapots with long spouts and are used to rinse the nasal passages with a saline (salt-based) solution. They have become popular as a treatment for congested sinuses, colds, and allergies, and for moistening nasal passages exposed to dry indoor air 6, 7. For more information on neti pots and other nasal rinsing devices, see FDA’s Consumer Update: Is Rinsing Your Sinuses Safe?

nasal irrigation - illustration of sniffing the water from the hands during ritual ablution.

For ritual nasal ablution information, please see Ritual Nasal Rinsing & Ablution.

Very rarely, Naegleria fowleri infections have been reported when people use contaminated tap water for nasal rinsing during showering 1, 2, irrigating, or cleansing their sinuses (nose) 3-5 for health or religious reasons. If you are using tap water directly or using tap water to prepare a saline or other type of solution for irrigating, flushing, or rinsing your sinuses with a neti pot, sinus rinse bottle, or other irrigation device, make sure the water is safe to use to protect yourself from infection.

 

To make your water safe for sinus rinsing and ritual nasal rinsing, it is safest to use boiled, sterile, or filtered water. If that is not possible, disinfect the water using chlorine; the cloudiness of the water can affect the ability to disinfect the water.

Take at least one of these actions to lower your risk of becoming infected with Naegleria during nasal rinsing.

Treating Water Used for Nasal Rinsing

1. Boiled or distilled (preferred)

  • Boil: Use water that has been previously boiled for 1 minute and left to cool.
    • At elevations above 6,500 feet, boil for 3 minutes.
  • Buy: Use water with a label specifying that it contains distilled or sterile water.

2. Filter (if boiled, sterile, or distilled water not available)

Filter: Use a filter designed to remove common germs.

  • The label should read “NSF 53” or “NSF 58” or contain the words “cyst removal” or “cyst reduction”. If these words are present it means the filter can remove Naegleria. See more information about reading filter labels.
  • Filter labels that read “absolute pore size of 1 micron or smaller” are also effective at removing Naegleria.
  • Some manufacturers of nasal rinsing devices recommend using 0.2 micron absolute pore size filters that will also remove many types of bacteria; these would also remove Naegleria. Follow the manufacturer recommendations if 0.2 micron absolute filters are recommended.

3. Disinfect (if no boiled or distilled water and no filter available)

Disinfect: Learn how to disinfect your water to make it is safe from Naegleria.

If you are unable to use 1) boiled or 2) sterile/distilled or 3) filtered water, you can use chlorine bleach to treat the water using the following instructions. If the water being treated is cloudy or murky (turbid), those particles may protect Naegleria from being killed by the chlorine. Because of that, we recommend filtering cloudy water first to remove particles and then using a double dose of chlorine disinfectant. The protocol below for disinfection with bleach is intended only to be used for nasal rinsing and not to be used for routine or emergency drinking water disinfection. We have added an extra amount of bleach to this protocol for an additional safety factor that is higher than that used for treating drinking water. If you need to disinfect drinking water, please see Emergency Water Supply Preparation.

If the water is clear:

  • Obtain a medicine dropper and add the number of drops shown in the table below of unscented liquid household chlorine bleach for the amount (one gallon or one quart/liter) of clear water to be disinfected. Use the % sodium hypochlorite shown on the label (either 4 to 5.9% or 6 to 8.25%).

If the water is cloudy, murky, colored, or very cold:

  • Filter water through a clean cloth, paper towel, or coffee filter

OR

  • Allow any sediment to settle to the bottom of your container, then carefully pour the clear water from the top into a clean container with as little disturbance of the sediment layer as possible.

THEN

  • Obtain a medicine dropper and add the number of drops of unscented liquid household chlorine bleach shown in the table below for the amount (1 gallon or 1 quart/liter) of clear water to be disinfected. Use the % sodium hypochlorite shown on the label (either 4 to 5.9% or 6 to 8.25%).
  • Stir the mixture well.
  • Let it stand for 30 minutes or longer before you use it.
  • Store the disinfected water in clean, sanitized, covered containers.
Disinfection of Water Used for Nasal Rinsing
  Drops for Clear Water Drops for Cloudy Water
Percent Bleach (Sodium Hypochlorite) Used 1 quart or liter

1 gallon

 1 quart or liter 1 gallon
4–5.9% 5 20 10 40
6–8.25% 4 13 8 26

If liquid bleach is not available for disinfection, solid chlorine tablets or powder may be used. Two common forms that may be available are chlorinated isocyanurates and calcium hypochlorite. See below for links that may be helpful in mixing disinfecting solutions using solid chlorine tablets or powder. Because there are so many different types and sizes of tablets available (containing different amounts of chlorine), you should follow the manufacturer’s instructions for disinfection.

4. Science behind the recommendations

The inactivation data for Naegleria is limited 1-6 but recent CT values (concentration of disinfectant [mg/l] X contact time [in minutes]) have been developed 5. Under laboratory conditions, chlorine at a concentration of 1 ppm (1 mg/L) added to 104.4°F (38°C) clear well water at a pH of 8.01 will reduce the number of viable and more resistant Naegleria fowleri cysts by 99.99% (4 logs) in 56 minutes (CT of 56) 4. The bleach disinfection protocol is based on using this CT of 56 and increasing the amount of bleach to give a 5-fold safety factor* for the lowest concentration in the range used in the table. This is added to account for the unknown quality, organic content, pH, and temperature of the water to be treated, which can reduce the amount and efficacy of the bleach available for disinfection. For visibly cloudy water, the amount of bleach to add has been doubled since particles and organic matter in the water will also react with the chlorine. The protocol below for disinfection with bleach is intended only to be used for nasal rinsing and not to be used for routine or emergency drinking water disinfection. As mentioned above, we have added an extra amount of bleach to this protocol as an additional safety factor that is higher than that used for treating drinking water. If you need to disinfect drinking water, see Emergency Water Supply Preparation.

Disinfection of Water Used for Nasal Rinsing*
  Drops for Clear Water
No. drops (chlorine concentration range using lower and upper bleach percentages listed in column one, ppm or mg/l)		 Drops for Cloudy Water
No. drops (chlorine concentration range using lower and upper bleach percentages listed in column one, ppm or mg/l)
Percent Bleach (Sodium Hypochlorite) Used 1 quart or liter 1 gallon 1 quart or liter 1 gallon
4-5.9% 5
(10 – 14.7)		 20
(10.5 – 15.6)		 10
(20 – 29.5)		 40
(21 – 31)
6 – 8.25% 4
(12 – 16.5)		 13
(10.3 – 14.2)		 8
(24 – 33)		 26
(20.6 -28.3)

*The dosage calculations are based on 20 drops per ml (50µl/drop) and 3.8 liters per gallon. The formula for the calculation is shown below. It calculates the dose needed to achieve a CT of 56 and then multiplies by the safety factor of five to account for other particles or organic material in the water that could use up the chlorine:

chlorine disinfection formula

If Naegleria fowleri amebae are present in tap water, nasal rising with tap water likely increases the risk of transmission compared to drinking the water. In addition, the potential outcome is much more severe than illness caused by most other waterborne pathogens. As a result, a five-fold protective factor has been adopted in these calculations to increase safety.

References
  1. Chang SL. Resistance of pathogenic Naegleria to some common physical and chemical agents. [PDF – 8 pages] Appl Environ Microbiol. 1978;35:368-75.
  2. 3.Tiewcharoen S, Junnu V. Factors affecting the viability of pathogenic Naegleria species isolated from Thai patients. J Trop Med Parasitol. 1999;22:15-21.
  3. De Jonckheere J, van de Voorde H. Differences in destruction of cysts of pathogenic and nonpathogenic Naegleria and Acanthamoeba by chlorine. [PDF – 4 pages] Appl Environ Microbiol. 1976;31:294-7. (1mg/l for an hour for cysts)
  4. Cursons RT, Brown TJ, Keys EA. Effect of disinfectants on pathogenic free-living amoebae: in axenic conditions. [PDF – 5 pages] Appl Environ Microbiol. 1980;40:62-6.
  5. Sarkar P, Gerba C. Inactivation of Naegleria fowleri by chlorine and ultraviolet light. J AWWA. 2012;104:51-2.
  6. Robinson BS, Christy PE. Disinfection of water for control of amoebae. Water. 1984;September:21-4.

 

References
  1. Cope JR, Ratard RC, Hill VR, Sokol T, Causey JJ, Yoder JS, Mirani G, Mull B, Mukerjee KA, Narayanan J, Doucet M, Qvarstrom Y, Poole CN, Akingbola OA, Ritter JM, Xiong Z, da Silva A, Roellig D, Van Dyke R, Stern H, Xiao L, Beach MJ. The first association of a primary amebic meningoencephalitis death with culturable Naegleria fowleri in tap water from a U.S. treated public drinking water system. Clin Infect Dis. 2015;DOI: 10.1093/cid/civ017.
  2. Dorsch MM, Cameron AS, Robinson BS. The epidemiology and control of primary amoebic meningoencephalitis with particular reference to South Australia. Trans R Soc Trop Med Hyg. 1983;77(3):372-7.
  3. Yoder JS, Straif-Bourgeois S, Roy SL, Moore TA, Visvesvara GS, Ratard RC, Hill V, Wilson JD, Linscott AJ, Crager R, Kozak NA, Sriram R, Narayanan J, Mull B, Kahler AM, Schneeberger C, da Silva AJ, Poudel M, Baumgarten KL, Xiao L, Beach MJ. Deaths from Naegleria fowleri associated with sinus irrigation with tap water: a review of the changing epidemiology of primary amebic meningoencephalitis. Clin Infect Dis. 2012;1-7.
  4. Shakoor S, Beg MA, Mahmood SF, Bandea R, Sriram R, Noman F, Ali F, Visvesvara GS, Zafar A. Primary amebic meningoencephalitis caused by Naegleria fowleri, Karachi, Pakistan. Emerg Infect Dis. 2011;17(2):258-61.
  5. CDC. Primary amebic meningoencephalitis associated with ritual nasal rinsing — St. Thomas, U.S. Virgin Islands, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(45):903.
  6. Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. J Fam Practice. 2002;51(12):1049-55.
  7. Rabago D, Zgierska A. Saline nasal irrigation for upper respiratory conditions. Am Fam Physician. 2009;80(10):1117-9.

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