Why Create a National Model Aquatic Health Code?

LCDR Jasen Kunz, MPH, REHSCenters for Disease Control and Prevention

Environmental Health Services Branch

New York State Conference of Environmental Health Directors

3-23-2011

National Center for Environmental HealthDivision of Emergency and Environmental Health Services

Factors Contributing to Spread of Pathogens in

Treated Swimming Venues

Waterborne pathogens commonly cause infection and can cause diarrhea

Diarrheal illness is common

Exposure to recreational water is common

Swimming is communal bathing

Fecal contamination of recreational water is common

Swallowing recreational water is common

Inadequate pool operation and maintenance not uncommon

Diarrheal Illness is Common

• 5% of general public had diarrhea in past month1

• 0.6 episodes of diarrhea/person/year1

• 0.1–3.5 cases of diarrhea/person/year (higher for young children)2

1. Jones TF et al. 2007. Epidemiol Infect 135(2):293–301.2. Roy SL et al. 2006. J Water Health 4(Suppl 2):31–69.

Percentage Previously Infected with Cryptosporidium in the United States,

by age group1

1. Frost FJ et al. 2004. Ann Epidemiol 14(7):473–8.

0

20

40

60

80

100

<11 11–20 21–30 31–50 51–70 >70

Age in Years

% P

revi

ou

sly

Infe

cted

Exposure to Recreational Water is Common:

Americans Swim…a Lot

Swimming is the 3rd most popular exercise activity in the United States1

~314 million swimming visits each year1

Underestimate >7 years of age Swim >6 times in last year

1. US Bureau of the Census. 2010 Statistical Abstract of the United States. Recreation and Leisure Activities: Participation in Selected Sports Activities 2007. Available at

http://www.census.gov/compendia/statab/2010/tables/10s1212.pdf

Swimming is Communal Bathing

Swimming = Sharing the water and contaminants in it

Actions of pool operator and swimmers affect others

Heavy use by diapered and toddler-aged children

>Fecal incidents common

• 293 formed stools in 47 pools, etc.2

~0.14g of feces on peri-anal surface/person Range: 0.01g (adults)–10g (children)3

Fecal Contamination of Recreational Water is Common

1. Nelson R et al. 1995. JAMA 274(7):559–61.2. CDC. 2001. MMWR 50(20):410–2.3. Gerba CP. 2000. Quant Microbiol 2(1):55–68

Swallowing Recreational Water is Common: Water Swallowed While Swimming,

by Age Group1

GroupAverage Amount of

Water Swallowed (mL)*Range (mL)

Adults 16

(~ ¼ yogurt) 0–53

Non-adults37

(~ 1 cup yogurt) 0–154

1. Dufour AP et al. 2006. J Water Hlth 4(4):425–30.

* Swimmers stayed in pool and actively swam for >45 minutes.

Pool inspection data from 4 state and 11 local pool inspection programs

Conducted January 1–December 31, 2008

Inspected >120,000 pools1

12.1% of inspections resulted in immediate closure pending correction of violation

1. CDC. 2010. MMWR 59(19):582–7.

Inadequate Pool Operation and Maintenance is NOT

Uncommon

Outbreaks: What’s in the Water?

San Alfonso del Mar in ChileLength: 3,323 ft long

Depth: 115 ft (deep end)Volume: 66 million gallons

Recreational Water Use is Associated with a Spectrum of Illness in Treated Aquatic Venues

Acute gastroenteritis Cryptosporidium, toxigenic E. coli,

Giardia, Shigella, norovirus, chemicals Dermal infections

Pseudomonas dermatitis/folliculitis, fungal infections

Ear infections (e.g., Pseudomonas) Eye infections and irritation

Adenoviruses, chloramines Respiratory infections and irritation

Legionella, Mycobacterium, chloramines, chemicals

Neurologic infections (e.g., Echovirus) Hepatitis (HAV) Urinary tract infections (e.g., Pseudomonas)

Recreational Water-Associated Outbreaks by Predominant Illness and Route of Entry:

Treated Venues, U.S., 1995–2004

Route of Entry (n=159)

Contact37.7%

Inhalation11.3%

Ingestion 50.9%

Environmental contaminants &

biofilms

Bather contaminants

Recreational Water Illness Outbreaks, United States, 1978–2008*

0102030405060708090

78 82 86 90 94 98 2002 2006

Year

Nu

mb

er o

f O

utb

reak

s

* N=685, includes preliminary 2007 and 2008 data (as of 10/14/2009), Yoder JS et al. 2008. MMWR 57(SS-9):1–38.

Recreational Water Illness Outbreaks, United States, 1978–2008*

Dermatitis

0

5

10

15

20

25

78 82 86 90 94 98 2002 2006

Year

Nu

mb

er o

f O

utb

reak

s

* N=229, includes preliminary 2007 and 2008 data (as of 10/14/2009), Yoder JS et al. 2008. MMWR 57(SS-9):1–38.

Recreational Water Illness Outbreaks, United States, 1978–2008*

Gastroenteritis

0

10

20

30

40

50

60

78 82 86 90 94 98 2002 2006

Year

Nu

mb

er o

f O

utb

reak

s

* N=335, includes preliminary 2007 and 2008 data (as of 10/14/2009), Yoder JS et al. 2008. MMWR 57(SS-9):1–38.

How Might We Prevent Disease?

Why Doesn’t the Government Protect Me?

Current Pool Code Situation

Jurisdiction Enacted at state/local level

Variability Significant variation across USA

Uniformity Lack of uniform national standards covering all

design, construction, operation and maintenance needs for all treated recreational venues

Responsiveness: Difficult to update; many codes out of date and

don’t reflect evolving science

Impetus for MAHC

CDC sponsored workshop “Recreational Water Illness Prevention at

Disinfected Swimming Venues” February 15-17, 2005 in Atlanta, Georgia

Recommended a need for: Data-driven, knowledge-based, risk reduction, public

health effort to prevent disease and injuries National model code that would allow health

jurisdictions to pull needed information for creating local codes

Regular updating of model code based on new data Open access to information in model code

Funding and Process

NSPF Board Grant Spark plug funding

Arch Chemical Travel funding

CDC MAHC effort started in

2007 Volunteer effort

MAHC Vision and Objective

A MAHC that is user-friendly, knowledge-based, and scientifically supported in an effort to reduce risk and promote healthy recreational water experiences.

The MAHC will transform varied swimming pool regulations used by health departments into a uniform set of state and local codes that ensure the health and safety of the swimming public.

MAHC Scope

All areas of public health concern Public venues Water, air, facility exposures that

impact bathers Contact, ingestion, immersion, inhalation Infectious, chemical, safety

Leave other areas to building codes, etc.

Venue types Man-made water venues Health care-based pools Therapy pools

MAHC Process

Transparent Process, work all posted on website for open

access

Inclusive Will include public health, aquatics sector, and

public

Communicative Will get message out to participate

Timely Put information out quickly when completed and

grade depending on level of data support Use modular format

MAHC Plan

Data or best practices driven Avoid prescription when possible

Modular Easier to complete if modules are updated rather

than entire code

Current and updated Will be modeled after the Conference for Food

Protection where a clear process is put in place to revise on a biennial basis based on new data

Free and accessible for all Web accessible

MAHC Outcomes

Reductions in RWIs Adoption of minimum standards throughout

the U.S. (as with national food safety and building model codes)

Need for mandatory training and education Improved surveillance systems Improved data collection Data-based decision making Systems-based approaches to facility design,

maintenance, and operation Research agenda

MAHC Process

Steering Committee (Director, 9 members)

Coordinator & Assistant to Director

Technical Committee

Public Comment

Technical Committee

Technical Committee

Biennial Conference

New or Revised MAHC Module

MAHC Directorate

Director Douglas Sackett, NYS Dept. of Health

MAHC Coordinator Lee Tate, CDC

Assistant to the MAHC Director Amanda Long, NYS Dept. of Health

MAHC Steering Committee

Guides MAHC process; sets priorities; creates TC’s and picks chairs; advises on process/objectives

Exercises editorial control of TC products Ensures uniformity and fit with mission/objectives

Chip Cleary, Palace Entertainment Water Park Group Tracynda Davis, representing NEHA Jim Dunn, Aquatic Development Group John Linn, Busch Entertainment Corp. Colleen Maitoza, County of Sacramento Charles Neuman, Water Technology Inc. Bob Vincent, Florida Department of Health Charles Otto, Michael Beach, CDC

MAHC Technical Committees

Formulate and creates new code modules

Examine existing technologies and

methodologies

Determine scientific basis for

recommendations and criteria

Identify scientific information gaps

Outline data needed for future revisions

MAHC Technical Committees

Contamination Burden Chair: Ellen Meyer, Arch Chemicals

Design and Construction Chair: Carl Nylander, Councilman & Hunsaker

Facility Maintenance and Operation Chair: Michael Beatty, Disney

Hygiene Chair: Ralph Cordell, CDC

Lifeguarding/Bather Supervision Chair: Kathryn Scott, UC Berkeley

Monitoring and Testing Chair: Sung Choe, NSF International

MAHC Technical Committees

Operator Training Chair: Dennis Berkshire, Aquatic Design Group

Recirculation Systems and Filtration Chair: James Amburgey, University NC

Regulatory Program Admin Chair: Frank Guido, Westchester Cty Dept Health

Risk Management/Safety Chair: Amy Duck, Disney World

Ventilation And Air Quality Chair: Franceen Gonzales, Great Wolf Resorts

Water Quality Chair: Jim Dingman, Underwriters Lab

MAHC Layout Code section

Easily read Organized by number and

cross-referenced across sections Design and construction Operation and maintenance Policies and management

Appendices Supporting information for code Guidance for disease and injury prevention

Start with “Best Practices” and upgrade as needed

Design and Construction Materials Structural stability Safety requirements Lighting Electrical Ventilation (indoor air quality, humidity) Water supply Wastewater disposal Circulation systems Filtration Disinfection/pH Hygiene facilities Water temperature control Construction (new, alterations,

replacements)

Operation and Maintenance Water quality parameters Safety parameters Recirculation parameters Indoor air quality parameters Peripheral items (e.g., slides) Hygiene facilities Monitoring and testing Facility maintenance Potable water and sewage systems Re-opening procedures (after closure) Preventive maintenance plan

Policies and Management

Lifeguard training Operator training Staffing/Employee illness plan Fecal incident/body fluid policies Swimmer empowerment methods Bather load policies Chemical handling Signage Pool shock Emergency response plan

Process and Status

Post modules for 60 day public comment CDC Healthy Swimming website Address public comments Post final version Revise thru “Conference for Swimmer Protection”

12 modules in various degrees of SC review Edit for uniformity

MAHC Editor hired by NCEH First module posted in July 2010 for 60 day

comment All modules up for initial posting in 2011 Final 1st edition posted in 2011

MAHC Changes/Requirements

Operator training required Training course elements defined

Secondary disinfection (e.g., UV, ozone) required on “high risk” pools

Chemical controllers required Chemical storage room guidelines Air ventilation requirements improved Regulatory program guidance, best

practices Annex explaining rationale

MAHC Launch and Evaluation

Launch package to alert users Public Health Law package to facilitate

usage/adoption Evaluative tools for tracking implementation

Process indicators (i.e., wording elements in new codes)

Pool inspection data Key elements adopted (e.g., operator training required) Outcomes improved (i.e., decrease in critical violations

due to all operators being trained)

Health Outcomes Reduced case reporting and outbreaks, particularly of

cryptosporidiosis

Planning for the Future

1st edition of MAHC is published Transition to a permanent structure/organization

responsible for maintenance and updating

Strategic planning for future transition and replacement of SC and TC structure

Structure/organization to be developed: Formal process with regular meetings (e.g. biennial)

for hearing issues and proposed changes and to clarify/update the MAHC.

“Executive Board” made up of health officials, industry, academia, and pool users.

May be similar to the Conference for Food Protection (CFP).

http://www.cdc.gov/healthywater/swimming/pools/mahc/

More Information: Healthy Water Website

Environmental Public Health Online Course (EPHOC)

Environmental Public Health Online Courses (EPHOC) http://www.cdc.gov/nceh/ehs/Workforce_Development/EPHOC.htm

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Establishments

Newly Required Disclaimer From the Department of Health

and Human Services (Please Interpret as You See Fit)

"The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy“

Questions?

National Center for Environmental HealthDivision of Emergency and Environmental Health Services