Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations

NEHA Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations Hello everyone and welcome to the presentation "Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations: Unlocking the Potential Power of Aquatic Inspection Data." To ask questions about this presentation, please join the presenter in the networking lounge at the designated time listed on the agenda. I would now like to introduce Michele Hlavsa, Chief of the Healthy Swimming Program at the Centers for Disease Control and Prevention.

Thank you. So, before I get too far into this talk, I do want to acknowledge, I'm the one giving the talk but there's a lot of people who worked on this project, especially our state and local partners in Arizona, California, Florida, New York, and Texas, and colleagues at CDC who really helped make this project happen. So, in the next 30, 40 minutes or so, I want to cover the following, give you some background on overview of swimming, talk about national surveillance systems for recreational water-associated illness and injury, talk about the methods and results of what we did with our surveillance system. And in the discussion I want to get into the implications about the data that are going to be presented, examine some of the limitations, and share conclusions.

So, the background. So, the National Sporting Goods Association, an industry group, for 2009, said swimming was the fourth most popular sports activity in the United States. They estimate some 50,226,000 people, ages seven years or more, went swimming at least six times a year. This would translate to 301,356,000 swimming instances in the course of a year. We, at CDC, are looking at our own estimates of what -- how much Americans swim each year. We're finding preliminarily that there's at least a billion swimming visits in the U.S. each year. We think part of the problem with the National Sporting Goods data is that they're looking at people seven years and above. And as we know, when we go to the pools, it's oftentimes the six-year-olds and the younger kids that are at the pools. According to Pkdata, there's some 309,000 U.S. public aquatic venues, so pools or interactive water playgrounds, or hot tubs and spas.

So, with any form of physical activity, it's a great way to fight the U.S. obesity epidemic we're dealing with. One of the tools we have in our toolbox is water-based physical activity such as swimming, such as water aerobics. The benefit to water-based physical activity is it sometimes might be the only physical activity option for certain groups, those with medical restrictions such as knee replacements, the aging population. These people are probably not going to get up and go run a marathon, however going to a water aerobics class or swimming laps at the local pool might be an option.

And as with any form of physical activity, water-based physical activity offers great health benefits, both physical and mental, across the life span. It's a way to manage chronic illness. For example, arthritis patients do water-based physical activity and find that it alleviates joint and muscle pain. Postmenopausal women have been found to, you know, maintain bone health better when they do water-based physical activity. And there have been studies that show that children with anxiety and depression, you know, have alleviation of their symptoms when they get into the pool and hang out with mom and dad and friends and family. And so across the life span, there are definitely benefits.

Just like there are benefits, there's also drawbacks. Like any form of physical activity, there's some risk of illness and injury. So our public health goal when it comes to water-based physical activity is to maximize the health benefits while we minimize the risk for illness and injury. Now, to figure out how best to do that, we need surveillance data. We need data to tell us kind of what is the epidemiology of illness and injury associated with recreational water. And when I say "what is the epidemiology," I mean estimating the magnitude.

How many cases of illness and injury are there each year? Document the distribution. Where are they occurring? Are there certain settings where these pools are, like a hotel/motel versus a water park where people are getting ill or injured, or is it, you know, illness in our little kids who tend to be the ones who are really at the pools, versus our older adults? So, knowing who to target and where to target our efforts, that's what this distribution data tell us.

1 NEHA Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations And also track the natural history, so are the cases of illness going down in number each year or are they going up? So these kind of direct the rest of our public health efforts. They inform and evaluate efforts to prevent and control illness and injury and they give us an idea about where to best optimize our -- where to best target our efforts to optimize them.

So let's start with recreational water-associated outbreaks. So, recreational water-associated outbreak is the occurrence of illness or similar illness in two or more persons. And they're going to be epidemiologically linked by location and time of exposure to recreational water. When we talk about outbreaks, we can talk about, you know, illness or injury caused by chemicals or caused by germs or infectious pathogens. So this histogram here looks at our outbreak data that have been reported to CDC since 1978, the year which reporting began, through 2012, the last year for which we have finalized data.

We find that we have almost 900 outbreaks reported to CDC. And if we break them down a bit, you'll notice that the blue bars represent the number of outbreaks associated with aquatic venues, so our treated venues, our pools, hot tubs, spas, water playgrounds. And the orange bars represent outbreaks associated with untreated recreational water venues, like our lakes, our oceans, and our rivers. You'll see orange bars are pretty stable over time. It's the blue bars that increase over time. So we're definitely seeing an increase in outbreaks associated with aquatic venues.

And if we just focus on these outbreaks, we see some 650 outbreaks reported since 1978. And then if we break those down, we look at -- we can see that there's definitely a major player in these outbreaks, especially the increase we've seen over the last few years. You'll see the blue bars here increasing over time, especially since the late 1990's, and these represent outbreaks of cryptosporidiosis associated with our aquatic facilities, our pools, water playgrounds, hot tubs, spas. You'll see the orange bars and they represent outbreaks of Pseudomonas folliculitis, or hot tub rash. And the yellow bars represent, you know, the other outbreaks over time.

So, as I mentioned earlier, the blue bars, there's definitely an increase since the late 1990's, and those are driving the overall increase that we see in our outbreaks associated with recreational water. The orange bar, as you see, they kind of peak more so in the early '80s, and that's when hot tubs and spas first appeared on the scene and started making, you know, an entree into our homes and into our hotels and motels. So this was before we really knew how to operate and maintain them.

And the yellow bars, there's been an increase over time, I would say most notably since the mid-2000s, but that could be just better reporting methods. This stuff was always going on, these outbreaks were always going on, but now we have surveillance staff making, you know, good contacts across our state and local jurisdictions to make sure these outbreaks are recorded, reported, investigated, and that we're starting to document them and look at them.

So I talked about outbreaks, now I want to talk about drownings. So fatal drowning, there are about 4,000 annual deaths due to drowning in the United States each year. Drowning is the leading cause of injury death in children ages one to four years. And more than half of the drownings in this age group occur in a pool. In terms of non-fatal drownings, we see about 5,800 annual emergency department or ED visits. More than half of the patients are ages one to four years. About two-thirds of the drownings among children in this age group occur in a pool.

We also have pool chemical-associated health events. We see some 3,000 to 5,000 annual U.S. emergency department or ED visits each year, about half of these patients are less than 18 years old. And we see pool chemical-associated health events occur when chemicals are handled without proper protective equipment. So we see either respiratory distress caused by inhaling vapors or gases or we can see burns caused by splashes to the eyes or onto the skin. We see a mixing of incompatible chemicals causing this injury, and also not securing chemicals away from children.

So, to counter all of these illness and injury issues, CDC has spearheaded, along with the New York State Department of Health, the development of the Model Aquatic Health Code. As some of you might know, in

2 NEHA Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations 2005, the Council of State and Territorial Epidemiologists, or CSTE, called on CDC to develop a model code for our public aquatic venues. Between 2007 and 2014, CDC and New York State worked to lead a multi-stakeholder effort to develop this code. This effort included the aquatic sector as well as, you know, academics. This wasn't just public health dictating to aquatics what needs to happen. This was all the stakeholders at the table trying to make the best possible code based on the latest available science, and, if the science wasn't available, the best practices. In August 2014, CDC released the first edition of the MAHC. In July of 2016, the second edition or the 2016 edition of the MAHC was released.

So, given that seven years and a lot of people's time has been invested in the MAHC, how are we going to test the -- how are we going to look at the impact, the public health impact of the MAHC? Well it's really important to start looking at surveillance data. As we all know, surveillance data are kind of like the central nervous system to public health. They direct where public health efforts go. Our current surveillance systems, the ones that look at the outbreaks, the pool chemical injuries, the drowning, they're probably not going to pick up the positive effects or the negative effects of the MAHC any time soon. It's going to take years, if not decades.

So we tried to come up with a surveillance system that might be able to pick up, you know, in the interim, what's going on. And what we decided to do is to try to look at data that provides a real-time assessment of what's going on in our public aquatic venues. So we look at inspection data and we look at, you know, therefore, the operation and maintenance of our public aquatic venues. And we take violations to be, you know, the risk for illness and injury. So if a violation is identified in inspection, there's increased risk for illness and injury. So this is going to help us look at the impact of the MAHC in the more near term.

So what did we do? So, before we set up the National Aquatic Facility Inspection Surveillance -- the Network for Aquatic Facility Inspection Surveillance -- excuse me -- what we did is we decided we want to look at the number of public aquatic venues and routine inspections, and the percentage of inspections that resulted in immediate closure or that identified one more violations. We focused on 15 critical risk reduction MAHC elements in terms of where do we get our biggest bang for the buck in trying to minimize the risk for aquatic facility-associated illness, drowning, and pool chemical-associated health events.

And overall, to look at the data, we analyzed it as well as we -- as well as doing a stratified analysis. So we tried to break down the data by pool type, looking at pool versus hot tub/spa, and looking at pool category, wading pool versus interactive water play venue, for example. And what we tried to do is we tried to maximize the coverage of the public pools across the country. So we approached the top five states in terms of number of public pools. This would be Arizona, California, Florida, New York, and Texas. The pool codes are statewide in New York and in Florida. They go by county in California and Arizona. So, for those four states, we worked with the top five counties that were willing to work with us. So, sometimes it was five of the top six counties in terms of number of pools on this project. And then in the State of Texas the pool code can vary within a country. So we worked -- or were targeting to work with the most populous cities in Texas. And again, the goal was five cities in Texas.

And this is how kind of the data floated -- flowed in NAFIS. So, basically, what we did is we determined inspection items, and that was done by asking our state or local partner to send us their inspection form and their pool code. And we did our best guess at what items corresponded to the 15 MAHC inspection items I had mentioned earlier. Once we kind of took our stab at it, we sent it our state and local health partners, public health partners, and asked them to sign off on it. Once they signed off on what data we were going to focus on and looking at their data, we requested the data.

Now, once the data came here, we reformatted and standardized the data, analyzed the data, then we reported the findings back to each jurisdiction and obtained approval. So we didn't consider the analyses of any jurisdiction's data final until the jurisdiction signed off that yes, those data were filed. Then we took the data and we aggregated them and looked at the databases as one database and analyzed the data yet again.

3 NEHA Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations And here's what we found. So the 16 jurisdictions that worked with us looking at 2013 inspection data conducted over 84,000 routine inspections of over 48,000 public aquatic venues. Over 12 percent, or almost one in eight inspections, these are all routine inspections, resulted in immediate closure of a public pool or hot tub spa. Over three-quarters of the inspections identified at least one violation. We found a median of two violations per inspection. And inspections identified as many as zero or as many as 21 violations during one inspection.

So, previously I mentioned we were looking at, you know, these outbreaks and trying to minimize the outbreaks for aquatic facility-associated illness. The five items we focused on were whether or not there was proper free available chlorine or bromine concentration; proper pH, which, as you all know, maximizes the effectiveness of the halogen, the chlorine, or the bromine. We looked to see if the recirculation pump was approved, in good repair, or operating; whether the filter was approved, in good repair, or operable; and whether the automated chemical feeder was in good repair and operable.

Among these five issues, I want to focus on the chlorine, the pH, and the chemical feeder. So, among routine inspections, overall we found that almost 12 percent of inspections found a violation in terms of free available chlorine or bromine violation. Almost 15 percent of routine inspections identified a violation in terms of proper pH, so it was -- the pH was out of range. And over five percent of inspections identified an issue with the chemical feeder, whether it was not in good repair or not operable.

In terms of drowning and entrapment prevention, we focused on enclosures, such as fencing, walls, gates, and doors being in good repair, and the gates and doors being self-closing and self-latching. We looked to see inspection data on water being clear and the main drain being visible. We looked at main drain covers being compliant with the Virginia Graeme Baker Pool and Spa Safety Act or ASME/ANSI standard, or whether the covers or grates of the suction outlets were secured, in good place -- were secured in place and were in good repair. We looked at whether or not the lifeguards were qualified and adequately staffed, and whether or not appropriate safety equipment, such as a hook or a ring, were available and in good repair, or if safety equipment was present.

So, among these, I want to focus on enclosure and the safety equipment. Over five percent inspections identified an issue with the enclosure. And over 12 percent of inspections, so, over one in eight inspections, identified an issue with the safety equipment, whether it wasn't in good repair or whether the first aid kit wasn't present. So there was limited, you know, ability to save a drowning swimmer or help an injured swimmer.

When we look at other injuries, those that are not, you know, chemicals, that aren't associated with drowning, and aren't associated with entrapment, for example, the pool chemical-associated health events, we looked at chemicals labeled and stored safely or secured; hot tub/spa inspection, hot tub/spa temperature being less than four degrees Fahrenheit; and whether or not the protective overhead electrical wires or GFCI, the ground volt circuit interrupter electrical outlets, were available. Among these items, I want to focus on the hot tub/spa temperature. Over seven percent of routine inspections identified a violation with the spa temperature.

And the final two inspection items we focused on, just for general health and safety, would have been whether or not a qualified operator or responsible supervisor was on site, and substantial alterations or equipment replacement were approved. And here you see that wasn't an issue on very many pool and hot tub/spa inspections.

Our next step was to stratify the data and look at venue type. And by venue type, I mean pool versus hot tub/spa. When we looked at the inspection data, we found that about two-thirds of inspections were of pools, about 25 percent or a quarter were of hot tub/spas, and about another almost ten percent were unknown venue type. When we look specifically at hot tub/spa inspections, we found that 15 percent resulted in immediate closure, 19 percent identified disinfection concentration violations, 27.5 percent identified pH violations, and seven-and-a-half percent identified water temperature violations.

4 NEHA Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations When we look at specifically pool categories, these data weren't very helpful in the sense that it seemed like most pools were categorized as pools. However, we were able to look at wading pool interactive water play venue. In the future, we hope to look at other things in more detail, like these flow-through pools or these lazy rivers, and see if there's any issues. We want to make sure we're not seeing more violations with one type of pool versus another. But here's what we found.

When we focus on kiddie wading pools, we find that 21.6 percent of routine inspections resulted in immediate closure, 19.2 percent identified disinfectant concentration violation, and 26 percent identified pH violations. We then also tried to look at setting of the venue that was being inspected and we found that very difficult to do with the way the data are being stored right now. So when we look at the pool and spa inspections, we see that basically over 99 percent of inspections occurred in unknown settings. So the hot tub or spa, we're not sure whether it was in hotel/motel or water playgrounds. So this is something we definitely want to work on in the future because there might be different risks associated with different settings.

So, overall, what should the data tell us? So I think the number one take-home message is that environmental health practitioners play a really vital role in preventing aquatic facility-associated illness and injury when they do inspections, whether it's because inspection results in immediate closure or the identification of a violation that needs to be fixed. They're really on the front line protecting public health. Unfortunately, according to NACCHO or the National Association for City and County Health Officers, only 68 percent of U.S. local public health agencies regulate, inspect, or license public aquatic venues.

The second take-home messages looking at this data or this report is basically a call to all stakeholders to do better. Patrons and aquatic staff should not be getting sick or hurt at public aquatic facilities. We need to find a way to minimize risk. We're never going to completely eliminate it. Completely eliminating means not going to our public aquatic venues anymore, and that's definitely not what we want to do. We want to get that physical activity in and we want to exercise and spend quality time with our friends and family. So we definitely need to focus on minimizing risk.

The other thing is setting minimum standards and increasing them over time, that's the overall goal with the Model Aquatic Health Code, with the MAHC. It's evolution, not revolution. And basically what we want to do is raise the standards and make it increasingly harder for the bad apples to stay in the game. Most of us do a good job most of the time, is what the data are telling us. And whether we're public health or whether the aquatic sector is, we all need to raise our game to at least the minimum standard. And we're hoping that the MAHC helps us do that, whether we are public health or whether we are from the aquatic sector.

In terms of what these data say to public health, I think the take-home message here is that inspections represent an opportunity to educate operators about how and why to properly operate their venues. It's about preventing repeat violations and, you know, not finding the same standards being violated time after time. It's about being a prevention advisor, an illness and injury prevention advisor to our operators to make sure, you know, the public is healthy and safe, and to minimize venue-based risk for illness and injury. If we can address issues and not have them repeated, that's all the better for public health.

I think the data also say we need to do inspector training. What we found when we started looking at the data by jurisdiction is we're not all doing inspections the right way. And perhaps we need to set our not only standards for the aquatic sector, but for ourselves as public health practitioners, you know, to maintain a minimum standard and to make sure that we're inspecting in a way that promotes public health.

Another take-home message is to increase awareness of access to inspection results. We encourage health departments to post inspection scores on their websites. If not, you know, have them posted at the poolside or at the entrance of the aquatic facility, just so the public is aware of it. I think, in general, we're very aware of restaurant inspections in the U.S. We hear inspection restaurant -- or restaurant inspection results on our radios, on our TVs, but you never hear about pool inspections. You know, in restaurants,

5 NEHA Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations where we eat food and we put food in our bodies, we expect to see inspection scores, you know, when we enter the restaurant. We should be doing the same for pools. We go -- before we immerse our bodies in that water, we should know what the inspection score is. And we recommend providing an overall inspection score or grade, so making it easier for the public to interpret and to incorporate into their swimming experiences.

Implications for aquatics, I think the take-home message is looking at inspections and the opportunity to learn about how and why to properly operate and maintain venues. It's about, you know, not viewing the inspection as, you know, a possibility of getting shut down and losing money and, you know, having upset patrons, but rather, you know, we get used to doing things a certain way. Having another pair of eyes come in and look at it and say, "Nope, you could do this better or that better," is an awesome opportunity.

There's also the issue of operator training. We should all have our operators trained. It's not as easy as just throwing chlorine into the pool. It's pretty hard to maintain an aquatic facility well, and we all need training on how to do that better. And then review the 15 critical items that we talked about in this talk. You know, if you're in aquatics, do they match your priorities? I mean, this is what CDC saw as the biggest, you know, critical items to protecting public health. Does this match, you know, the pool operators and pool management's priorities? And do they match the staff priorities? You know, the management has an opportunity here to set the tone for that. And it's about, again, increasing awareness of and access to inspection scores, posting it waterside or at the entrance. It's not only about bad inspection scores; it's about a good inspection score. If you do well on your inspection, post it. Let your patrons know that you're doing a good job. And again, you could do that at the venue or online on your website.

In terms of the public, I think the messages to them that bathers and parents of young bathers need to take a more active role in keeping themselves and others healthy at our public aquatic facilities. And even our backyard residential ones, CDC recommends that people check inspection scores for their public aquatic venues to see if they're available. And regardless of what type of pool you're getting into or hot tub/spa, water playground, do your own abbreviated inspection, whether it's in a backyard or at a public facility. And if you do identify issues, let the operator know or let the beach manager know. And, you know, if they're not addressing the issue the way you want the issue to be addressed, go to the state or local public health agency and share what you found with them, and see if they can help you get the situation fixed.

In terms of limitations of data I presented, the results might not be generalizable to you as public aquatic venues nationwide. And we are only talking about 16 jurisdictions. There are thousands of local jurisdictions across the U.S. However, you could say that 15.7 percent of the public aquatic venues in the U.S., the almost 310,000 aquatic venues across the U.S., you could say almost one in six are represented within the surveillance system called NAFIS.

The number of venues of inspections of each venue vary across jurisdictions. So, some jurisdictions are doing many inspections of each venue, each year. Some jurisdictions just have a lot of venues. So this isn't like we had 500 inspections for each jurisdiction that was participating. So, some jurisdictions contributed more inspection records than others. And there wasn't an overall standard across jurisdictions. When I talked about these violations, they were always specific to each jurisdiction. So what might be a violation in one jurisdiction might not be a violation in another. And an inspection that results in passing might not result in passing in another jurisdiction. So, just things to keep in mind.

The overall conclusion is, you know, these inspection data are really valuable data and they can be used to determine the magnitude of closures and violations and advocate for environmental health programs. There is a lack of awareness of full inspections across the U.S. by the public, and I think that kind of helps local health departments, you know, in terms of not having full inspection programs. You don't know about them, you don't value them. But if we start talking about how many pools we're closing immediately on routine inspections -- some of these routine inspections are announced -- if we start talking about the

6 NEHA Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations violations that are identified and just increasing public awareness, we can better advocate for the limited finite public health funds and advocate for pool inspection programs.

The second is to use inspection data to characterize distribution for closures and violations by venue types, so pool versus hot tub/spa pool categories, or kiddie wading pools, or surf water playgrounds versus, you know, someday hopefully our lazy rivers, et cetera. And for setting -- you know, we hope to get those data in the future as well. You know, are we talking about hotel/motels versus water parks? All these data will tell us where we need to go. And if we know which violations we are, then we know where our education efforts need to be focused.

And, you know, once we know where the issues are, we can say, "Okay, if I have so much -- so many resources to do inspections, why don't I start doing risk-based inspections?" You know, maybe that one facility which hasn't had a violation in two years isn't where you go three times a year. But that hotel/motel pool or that water park that you keep shutting down, that's the place where you go and you do ten inspections a year if needed to bring that standard of operation and maintenance up. And then finally, you know, these data tell us how well or not well our prevention efforts work. After we put the targeted education efforts in and after we put the targeted enforcement efforts in based on our data, do we see a decline in our closures and violations over time?

So lessons learned really need to be shared. I think, you know, working with all these health departments, they all have different database vendors and they all have their own systems. So we've really worked on reaching out to our database vendors and looking at ways we can optimize data collection storage to facilitate data analysis. I will tell you, looking at 16 jurisdiction data took nine months of full-time by a statistician, of who I call our data ninja, reformatting and standardizing our data. And if it's taking her this long to look at 16 jurisdictions' data, I'm guessing most jurisdictions can't readily access, extract their data, and analyze it. So how do we facilitate this for our state and local partners?

And in terms of, you know, when I first started talking about this I was talking about trying to get five jurisdictions from the five states, but we're only talking about 16 jurisdictions worth of data. There were some difficulties in terms of jurisdictions accessing new data, extracting their data, and sending their electronic inspection data. So there is this need for us to start working together with our database vendors to facilitate this, to make routine analysis of inspection data, you know, readily available and easy to do. And I have a link here on this slide that talks about how after analyzing data we would recommend setting up a database just to facilitate, you know, routine analysis.

In terms of environmental health, we're talking about looking for environmental health leaders, environmental health practitioners taking the lead in multidisciplinary teams that include epidemiologists and IT specialists to unlock the data so that they do, you know, start being available to advocate for programs, to help us direct where to put our education enforcement efforts, as well as evaluate our prevention efforts. Environmental health practitioners, they're the ones who know how to properly operate and maintain a pool. They're the ones who know how routine inspections are done. So they really should lead any effort to facilitate routine analysis of the data.

What the epidemiologists brings to the table is knowing how to run a surveillance system. So, you know, looking at inspection data as surveillance data would not be very foreign to them. And, you know, they could share their experiences with looking at surveillance data and conducting analyses to promote routine analysis of inspection data. And IT specialists, how are we storing these data? How are we putting these data, you know, into a system in such a way that we can easily extract it or access it or run analyses on it? And I think it would be really great if we could work under environmental health leadership to kind of get this up and running and make it part of pool programs across the country.

The other thing to think about is, you know, this is 2013 pool, hot tub, spa inspection data, it's just a snapshot of the operation and maintenance of some public aquatic venues. We hope this is a baseline to evaluate the MAHC, but we will see over time. So, here is my contact information. If you do have any questions or want any assistance, I encourage you to contact me or work with my colleague, Jason

7 NEHA Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations Koons [ph] over at National Center for Environmental Health. We'll do what we can to promote routine inspection analysis. And, you know, this focused on aquatic venue inspections or aquatic facility inspections. This can really be applied to any type of inspection. So, you know, whether it was looking at body art establishments or, you know, food restaurant inspections, this is something to be thinking about. Here's a required disclaimer. And I'd just like to say thank you.

Thank you, Michele. And thank you everyone for attending today's webinar "Network for Aquatic Facility Inspection Surveillance Data on Immediate Closures and Violations: Unlocking the Potential Power of Aquatic Inspection Data." On behalf of the National Environmental Health Association and our presenters, thank you for joining us today and have a great rest of your day.