Why Create a National Model Aquatic Health Code?

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Why Create a National Model Aquatic Health Code?

• LCDR Jasen Kunz, MPH, REHS
• Centers for Disease Control and Prevention
• Environmental Health Services Branch
• New York State Conference of Environmental Health
  Directors
• 3-23-2011

National Center for Environmental Health
Division of Emergency and Environmental Health
Services
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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

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Diarrheal Illness is Common

• 5 of general public had diarrhea in past month1
• 0.6 episodes of diarrhea/person/year1
• 0.13.5 cases of diarrhea/person/year (higher for
  young children)2

1. Jones TF et al. 2007. Epidemiol Infect
   135(2)293301.
2. Roy SL et al. 2006. J Water Health 4(Suppl
   2)3169.

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Percentage Previously Infected with
Cryptosporidium in the United States, by age
group1
1. Frost FJ et al. 2004. Ann Epidemiol
14(7)4738.
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Exposure to Recreational Water is Common
Americans Swima Lot

• Swimming is the 3rd most popular exercise
  activity in the United States1
• 314 million swimming visits each year1
• Underestimate
• gt7 years of age
• Swim gt6 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
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Swimming is Communal Bathing

• Swimming Sharing the water and contaminants in
  it
• Actions of pool operator and swimmers affect
  others

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Fecal Contamination of Recreational Water is
Common

• Heavy use by diapered and toddler-aged children
• gtFecal 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

1. Nelson R et al. 1995. JAMA 274(7)55961. 2.
CDC. 2001. MMWR 50(20)4102. 3. Gerba CP. 2000.
Quant Microbiol 2(1)5568
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Swallowing Recreational Water is Common Water
Swallowed While Swimming, by Age Group1
Group Average Amount of Water Swallowed (mL) Range (mL)
Adults 16 ( ¼ yogurt) 053
Non-adults 37 ( 1 cup yogurt) 0154
Swimmers stayed in pool and actively swam for
gt45 minutes.
1. Dufour AP et al. 2006. J Water Hlth
4(4)42530.
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Inadequate Pool Operation and Maintenance is NOT
Uncommon

• Pool inspection data from 4 state and 11 local
  pool inspection programs
• Conducted January 1December 31, 2008
• Inspected gt120,000 pools1
• 12.1 of inspections resulted in immediate
  closure pending correction of violation

1. CDC. 2010. MMWR 59(19)5827.
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• Outbreaks Whats in the Water?

San Alfonso del Mar in Chile Length 3,323 ft
longDepth 115 ft (deep end)Volume 66 million
gallons
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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)

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Recreational Water-Associated Outbreaks by
Predominant Illness and Route of Entry Treated
Venues, U.S., 19952004
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Recreational Water Illness Outbreaks, United
States, 19782008
N685, includes preliminary 2007 and 2008 data
(as of 10/14/2009), Yoder JS et al. 2008. MMWR
57(SS-9)138.
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Recreational Water Illness Outbreaks, United
States, 19782008 Dermatitis
N229, includes preliminary 2007 and 2008 data
(as of 10/14/2009), Yoder JS et al. 2008. MMWR
57(SS-9)138.
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Recreational Water Illness Outbreaks, United
States, 19782008 Gastroenteritis
N335, includes preliminary 2007 and 2008 data
(as of 10/14/2009), Yoder JS et al. 2008. MMWR
57(SS-9)138.
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• How Might We Prevent Disease?
• Why Doesnt the Government Protect Me?

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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
  dont reflect evolving science

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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

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Funding and Process

• NSPF Board Grant
• Spark plug funding
• Arch Chemical
• Travel funding
• CDC
• MAHC effort started in 2007
• Volunteer effort

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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.

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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

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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

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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

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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

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MAHC Process
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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

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MAHC Steering Committee

• Guides MAHC process sets priorities creates
  TCs 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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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).

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More Information Healthy Water Website
http//www.cdc.gov/healthywater/swimming/pools/mah
c/
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Environmental Public Health Online Course (EPHOC)

• Environmental Public Health Online Courses
  (EPHOC) http//www.cdc.gov/nceh/ehs/Workforce_Deve
  lopment/EPHOC.htm
• Provide access to comprehensive, worthwhile and
  affordable workforce development resources for
  practitioners in environmental public health.
• This has been a major issue across the United
  States for the past decade.

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Environmental Public Health Online Course (EPHOC)

• EPHOC Target Audience
• New-hire environmental public health major with a
  science major
• Individuals preparing for state or national
  credential exam
• Environmental health and other students
• Environmental public health professionals wanting
  to improve their public health knowledge

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Environmental Public Health Online Course (EPHOC)

• EPHOC Courses
• General Environmental Health
• Statutes and Regulations
• Food Protection
• Potable Water
• Wastewater
• Solid and Hazardous Waste
• Hazardous Materials
• Disaster Sanitation

• Zoonoses, Vectors, Pests and Weeds
• Radiation Protection
• Occupational Safety and Health
• Air Quality and Environmental Noise
• Housing Sanitation and Safety
• Institutions and Licensed Establishments

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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

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Questions?
National Center for Environmental Health
Division of Emergency and Environmental Health
Services