Health-based monitoring of the Caspian Sea in Turkmenistan and Iran suggests that bathers are intermittently subject to increased levels of faecal pollution which may lead to gastrointestinal illness. This is the first co-ordinated monitoring programme of recreational waters in the Caspian region and highlights the need to extend such a programme to all countries bordering the Caspian Sea. The novel approach of monitoring that combines risk assessment (water quality monitoring plus a sanitary survey) and risk management, as applied here, allows the identification of possible sources of pollution and the levels of microbiological risk that bathers are subject to. Hence, this allows suitable management interventions to be identified and implemented in the long-term.