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. - PowerPoint PPT PresentationTRANSCRIPT
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
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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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