The July/August 2023 issue of the Journal of Environmental Health (Volume 86, Number 1), published by the National Environmental Health Association.
JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional
Volume 86, No. 1 July/August 2023
www. neha.org
Published by the National Environmental Health Association
It’s simple for staff to get sanitizing right every time with these powerful, ready-to-use products that quickly kill 99.9% of viruses and bacteria. Plus, the one-step sanitizing and disinfecting formula is made to use on food-contact surfaces without rinsing so it’s even easier to help prevent cross-contamination . Available in spray and wipes. Fast, Easy, and Effective
Finally, There’s a Better Way to Wipe Out Germs
See how PURELL ® Surface Sanitizers do it. Visit Surfaces.GOJO.com/learn-more .
©2023 GOJO Industries, Inc. All rights reserved. | 34593 (01/2023)
JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional +<9B:2 $< B9F B4B@A
ADVANCEMENT OF THE SCIENCE Applying the Model Aquatic Health Code to Grade Swimming Pool Safety in a Large Metropolitan Area....................................................................................................... 8 Enveloped Phi 6 Bacteriophage Persistence and Cross-Contamination on the Surface of Farmers Market Fomites................................................................................18 Special Report: Federal Meat and Poultry Inspection Duties and Requirements—Part 3: Monitoring of Food Safety Systems ............................................................................................. 24 ADVANCEMENT OF THE PRACTICE Environmental Health Department Structure: Literature Review and Recommendations........ 28 Direct From CDC/Environmental Health Services: Equipping Educators to Empower Students With a Tracking Education Kit ...................................................................................... 34 Direct From ecoAmerica: Staying Cool in a Changing Climate: Caring for Health in Extreme Heat .......................................................................................................................... 38 NEW Spotlight on Success Stories From the Field: Active Managerial Control: Implementation and Insights ....................................................................................................... 40 ADVANCEMENT OF THE PRACTITIONER JEH Quiz #1............................................................................................................................... 17
ABOUT THE COVER
The Model Aquatic Health Code (MAHC) from the Centers for Disease Control and Prevention provides voluntary guidelines that reduce the risk of disease, injury, and
drowning at aquatic facilities. In this month’s cover article, “Applying the Model Aquatic Health Code to Grade Swimming Pool Safety in a Large Metropolitan Area,” the authors sought to develop a swimming pool safety grading system in a metropolitan area by applying the MAHC to city swimming pool inspection data. Overall, the MAHC can be applied to grade swimming pool safety in jurisdictions where it has not been adopted. Furthermore, the degree of safety violations can be spatially demonstrat- ed to inform injury prevention measures. See page 8. Cover image © iStockphoto: peedees
Environmental Health Calendar ...............................................................................................44
ADVERTISERS INDEX
Resource Corner........................................................................................................................ 45
Accela ................................................................... 43
JEH Author, Title, and Subject Index: Volume 85. .................................................................... 46
American Public Health Association (APHA)...... 37
YOUR ASSOCIATION President’s Message: Environmental Health Professionals: Stand Up and Be Recognized ........................ 6
GOJO Industries..................................................... 2
Hedgerow Software, US, Inc. ................................ 59
Special Listing ........................................................................................................................... 50
HS GovTech.......................................................... 60
National Onsite Wastewater Recycling Association (NOWRA)........................................... 5
NEHA 2023 and 2024 AEC....................................................................................................... 52
NEHA News .............................................................................................................................. 54
NSF....................................................................... 33
NEHA Member Spotlight .......................................................................................................... 58
3
July/August 2023 • <B?;.9 <3 ;C6?<;:2;A.9 2.9A5
Find Your People. Find Your Training. Find Your Resources.
Join our environmental health community. It is the only community of people who truly understand what it means to do what you do every day to protect the health of our communities. Join us today. Your people are waiting. neha.org/membership
in the next Journal of Environmental Health don’t miss A Collaborative Approach to National Food Code Adoption Federal Meat and Poultry Inspection Duties and Requirements—Part 4: Food Defense, Product Sampling, Rules of Practice, and Summary Needs Assessment of Environ- mental Health Professionals in Montana: A Post-COVID-19 Perspective
Official Publication
Published monthly (except bimonthly in January/February and July/ August) by the National Environmental Health Association, 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910. Phone: (303) 802- 2200; Fax: (303) 691-9490; Internet: www.neha.org. E-mail: kruby@ neha.org. Volume 86, Number 1. Yearly subscription rates in U.S.: $150 (electronic), $160 (print), and $185 (electronic and print). Yearly international subscription rates: $150 (electronic), $200 (print), and $225 (electronic and print). Single copies: $15, if available. Reprint and advertising rates available at www.neha.org/jeh. Claims must be filed within 30 days domestic, 90 days foreign, © Copyright 2023, National Environmental Health Association (no refunds). All rights reserved. Contents may be reproduced only with permission of the managing editor. Opinions and conclusions expressed in articles, columns, and other contributions are those of the authors only and do not reflect the policies or views of NEHA. NEHA and the Journal of Environmental Health are not liable or responsible for the accuracy of, or actions taken on the basis of, any information stated herein. NEHA and the Journal of Environmental Health reserve the right to reject any advertising copy. Advertisers and their agencies will assume liability for the content of all advertisements printed and also assume responsibility for any claims arising therefrom against the publisher. The Journal of Environmental Health is indexed by Clarivate, EBSCO (Applied Science & Technology Index), Elsevier (Current Awareness in Biological Sciences), Gale Cengage, and ProQuest. The Journal of Environmental Health is archived by JSTOR (www.jstor.org/journal/ jenviheal). All technical manuscripts submitted for publication are subject to peer review. Contact the managing editor for Instructions for Authors, or visit www.neha.org/jeh. To submit a manuscript, visit http://jeh.msubmit.net. Direct all questions to Kristen Ruby-Cisneros, managing editor, kruby@neha.org. Periodicals postage paid at Denver, Colorado, and additional mailing offices. POSTMASTER: Send address changes to Journal of Environmental Health , 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910.
Journal of Environmental Health (ISSN 0022-0892)
Kristen Ruby-Cisneros, Managing Editor Ellen Kuwana, MS, Copy Editor Hughes design|communications, Design/Production Cognition Studio, Cover Artwork Soni Fink, Advertising For advertising call (303) 802-2139 Technical Editors William A. Adler, MPH, RS Retired (Minnesota Department of Health), Rochester, MN Gary Erbeck, MPH
Retired (County of San Diego Department of Environmental Health), San Diego, CA Thomas H. Hatfield, DrPH, REHS, DAAS California State University, Northridge, CA Dhitinut Ratnapradipa, PhD, MCHES Creighton University, Omaha, NE
Printed on recycled paper.
4
Volume 86 • Number 1
NEHA MEMBERS Save 10% on NOWRA Online Training with Code NEHA2023
Offer expires December 31, 2023
EDUCATION
MEMBERSHIP
ADVOCACY
YOUR ASSOCIATION
PRESIDENT’S MESSAGE
Environmental Health Professionals: Stand Up and Be Recognized
Tom Butts, MSc, REHS
G reetings from Colorado. I am hon- ored to have been elected to serve as the 2023–2024 president of the National Environmental Health Association (NEHA). I have been a member since 1985. Prior to being elected to the NEHA Board of Directors, I served as the technical section co- chair for terrorism and all-hazard prepared- ness in 2003–2005 and counted NEHA elec- tion ballots back when they were paper. I have observed many changes at NEHA and am now part of working to assure we actively support the profession and build a solid foundation to continue that work moving forward. This work is not without its own challenges for a profession that regularly steps up to meet the ever-evolving list of national emerging issues to backyard disasters. The profession is faced with the need to evolve and grow. The profession is also challenged at times to manage direc- tives to trim back when economic pressures or other priorities impact their budgets—a hazard of being partly or fully funded by program fees. I have benefited from attending and pre- senting at a variety of NEHA Annual Educa- tional Conferences (AECs) over the years in great spots such as Denver, Anchorage, Las Vegas, Grand Rapids, and Spokane. I look forward to the 2023 AEC in New Orleans with anticipation about both the content and the people. The AECs and the variety of other webinars and continuing education programs and opportunities NEHA provides are quality ways to refresh knowledge, learn new skills, and engage with subject matter experts and peers from across the country.
attending many general and specialized train- ing and education programs provided by the Colorado Environmental Health Association (CEHA). The great annual educational con- ferences oered by the NEHA aliates are still the places many go to share successes and learn about new ways of doing our work. I joined CEHA as a student in 1984 and later served as a regional board member from 2007–2009 and treasurer from 2009– 2011 (yes, I did the ever-important organiza- tion tax 1099s and maintained our nonprofit good standing status). I then served as the CEHA president elect, president, and past president from 2016–2018. Working with my peers from across the state—from the uniformed services to retail food and waste- water industries—was rewarding and chal- lenging. This work helped me to understand the range of systems we operate in and the driving forces we need to acknowledge. Hav- ing support from my employer to participate in these roles to build skills and knowledge paid dividends when I took on leadership roles in the agency. Early in my career, I learned from the first environmental health director I worked for at Tri-County Health Department, Dr. Chris Wiant, that an environmental health group could play a key role identifying and working to address a wide range of commu- nity challenges. Dr. Wiant went on to serve as president of NEHA from 1992–1993. He was open to exploring new activities and programs, with the supporting funding of course, and while working to support and improve existing core environmental health programs. This exploration resulted in
I landed in the environmental health under- graduate program at Colorado State University after considering environmental engineering and other programs. The program appealed to my interests in science and the environ- ment, and how that impacts human health, disease control, and epidemiology. The final piece of this program was an internship with a toxicologist from Region 8 of the U.S. Envi- ronmental Protection Agency where I listened to community members impacted by sites in urban communities and in the rural Rocky Mountains, and witnessed the challenges of responding to large and complex sites with evolving environment data, health eects, and toxicology uncertainties. After graduating with a bachelor of science degree in environmental health with a minor in chemistry, I took an entry-level position as an environmental health specialist with the Tri-County Health Department in the Denver metropolitan area. I benefited from a well- crafted, agency-specific training program to become field ready. My knowledge and skills were also built, in a significant way, by We need to capitalize on the contacts and community members we interact with to demonstrate the value of our work.
6
+<9B:2 • $B:/2?
unique coordination with organizations that represented consumer product safety, local first responders, and healthcare providers. Dr. Wiant empowered the sta to participate in Local Emergency Planning Commissions, to learn and use GIS to map old landfills, and to work directly to represent local interests where Superfund sites impacted communi- ties. These eorts were supported by hiring engineers and occupational health sta (i.e., certified industrial hygienists) to address community hazards. During my career in environmental health at the local government level, I have had the pleasure of holding positions with responsi- bilities in food safety, water quality and waste- water, childcare, household chemical waste, hazardous waste, air quality, and emergency preparedness, along with leadership roles as the environmental health director and agency deputy director. Each position provided an opportunity to collaborate with peers to learn, grow, and engage. Currently, I am an environmental public health consultant. As community needs and interests change, so has the scope of the environmental health practice. It also varies widely with large agen- cies having up to 20 or more programs and small agencies only able to provide core pro- grams. Working to assure compliance with sound science-based regulations is founda-
tional for food safety, water quality, and other programs. Working to influence land use cases to address healthy eating, active living, environmental injustice, and local hazards is an important role as well. Explaining that all these issues are encompassed by environ- mental health is the real trick. NEHA and our members currently face the ongoing evolution of the food industry and must continue to engage with many partners to assure food safety. We also must find ways to keep and gain new funding and provide support for our communities. We should become more prepared for emerging issues such as harmful algal blooms and per- and polyfluoroalkyl substances (PFAS) in our water, wastewater, and biosolids. We must strengthen our risk communication skills to be prepared to engage with citizen science using low-cost tools to gather air and water quality data in our communities. The Spark! Leadership Series and Environmental Health Leadership Academy oered by NEHA are terrific programs to build skills and interface with experts and peers. Here are a couple of issues I hope you will see as priorities for our profession and NEHA: • Assure support for and recognition of envi- ronmental health practitioners and the key roles they play in protecting communities from adverse health impacts.
• Reinforce and enhance the value and rec- ognition of the Registered Environmental Health Specialist/Registered Sanitarian (REHS/RS) credential. • Encourage an active role for environmen- tal health professionals as evidence-based policy advocates as we work in all our environmental programs and to address environmental justice, sustainability, and climate change. I see governmental environmental health professionals as the most can-do part of the public health system. We have great part- ners in industry and academia that we must continue to actively work with and support where possible. Environmental health professionals have more contact with the community than any other element of the environmental public health system. We need to capitalize on the contacts and community members (e.g., the regulated community, local agency con- tacts, the public at large) we interact with to demonstrate the value of our work. As I reflect on the work we do, I like to say, “Pub- lic health is an important part of environ- mental health.”
President@neha.org
Did You Know?
For every $1 we receive in membership dues, we return $19 in the form of invest- ments in capacity building—leadership, training, and education. Join now to take advantage of this return on investment at www.neha.org/membership.
Show the world you are the environmental health expert you know you are with a credential. You might even earn more or get promoted. neha.org/credentials Stand out in the crowd.
7
July/August 2023 • Journal of Environmental Health
+$#$) % ) SCIENCE
Applying the Model Aquatic Health Code to Grade Swimming Pool Safety in a Large Metropolitan Area
Miguel A. Arroyo, Jr., MD Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital Jennifer L. Jones, MS Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital Antoine Nguyen University of Houston Rohit P. Shenoi, MD Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital
/@A?.0A The Model Aquatic Health Code (MAHC) provides voluntary guidelines that reduce the risk of disease, injury, and drowning at aquatic facilities. Its use varies across state and local jurisdictions. We sought to develop a swimming pool safety grading system in a metropolitan area by applying the MAHC to city swimming pool inspection data. We conducted a cross-sectional study that involved routine inspections of commercial aquatic venues in Houston, Texas, during 2016. We calculated the overall percentage of items in compliance with the MAHC. Next, we graded swimming pools by assigning points based on the MAHC to corresponding swimming pool violations and assigning a letter grade: A = 95–100%; B = 85–94%; C = 75–84%; and fail (F) = <75%. Graded pools were projected onto a map of Houston to geographically sort and visualize their location. There were 3,100 commercial aquatic venues in Houston that were inspected. Venues were graded for safety as: A = 40.2%; B = 0.5%; C = 0%; and F = 59.3%. Swimming pool enclosure violations were most frequent (18.0%). Most swimming pools, irrespective of the degree of pool safety violations, were located in the Southwest section of Houston. Overall, the MAHC can be applied to grade swimming pool safety in jurisdictions where it has not been adopted. The degree of safety violations can be spatially demonstrated to inform injury-prevention measures.
recommends multiple layers of protection to prevent drowning (Denny et al., 2021). Waterborne diseases, drowning, falling, div- ing, chemical use, and suction injuries are major recreational water illnesses and inju- ries (RWIs) associated with public aquatic facilities, particularly for young children. Between 2000–2014, there were 493 out- breaks of waterborne diseases associated with treated recreational water that resulted in at least 27,219 cases and 8 deaths (Hlavsa et al., 2018). Additionally, between 2003–2012 there were an estimated 4,247 emergency department visits for swimming pool chemi- cal-related injuries (Hlavsa et al., 2014). State and local agencies regulate safety at public aquatic facilities, as there is no fed- eral regulatory authority responsible for the design, construction, operation, mainte- nance, and management of public pools and hot tubs/spas. Public pool codes for prevent- ing and responding to RWIs are developed, reviewed, and approved by state and local public health ocials or legislatures and thus can vary among local and state jurisdictions. In 2007, the Centers for Disease Control and Prevention (CDC, 2023a) developed the Model Aquatic Health Code (MAHC) to provide guidance to local and state agencies regarding the design, operation, and main- tenance of public aquatic facilities to reduce RWIs. As a result, 25 jurisdictions located in the 5 states with the highest estimated counts of public aquatic venues—Arizona, Califor- nia, Florida, New York, and Texas—and a
Introduction Drowning is the leading cause of uninten- tional injury death in U.S. children 1–4 years (National Center for Injury Prevention and Control, 2018). In children, swimming pools account for 33% of fatal drownings (Clemens et al., 2021) and 65.7% of nonfatal submer- sions in the U.S. (Felton et al., 2015). During 2017–2019, an average of 6,700 pool- or spa- related nonfatal drowning injuries treated in
hospital emergency departments occurred each year in children <15 years; each year, an estimated 76% occurred in children <5 years (Yang, 2020). The risk of submersion is 2.7 times higher for a child at a multifamily residence com- pared with a single-family residence and 28 times more likely in a multifamily swimming pool than a single-family pool (Shenoi et al., 2015). The American Academy of Pediatrics
8
+<9B:2 • $B:/2?
3,107 public swimming pools, including spas and wading pools, in Houston during 2016. We defined a public swimming pool as one that is intended to be used collectively by people for swimming or bathing. This clas- sification included a swimming pool owned or operated as part of a multifamily dwelling project, nonprofit recreational facility, hotel, educational facility, or fitness center (Hous- ton Health Department, 2023a). In 2021, Houston had a population of 2.29 million (U.S. Census Bureau, 2021). The Houston Health Department regulates public pools and spas through enforcement of Chapter 43 of the City of Houston Code of Ordinances (City of Houston, 2023). The code was adopted from the Texas Administra- tive Code (Public Swimming Pools and Spas, 2023), Texas Health and Safety Code (Pool Yard Enclosures, 1994), and International Code Council, Inc. (2018). The ordinance ensures that aquatic facili- ties provide a clean, healthy, and safe envi- ronment for the public by protecting against waterborne illness and preventing drowning. The pool safety inspection consists of safety and administrative elements (Houston Health Department, 2019). All public pools, includ- ing multifamily and community swimming pools, require an annual inspection. More frequent inspections occur when safety viola- tions are discovered at the time of inspection or in response to a complaint. The city also lists critical violations that can result in immediate closure of the swim- ming pool (Houston Health Department, 2019). If uncorrected, these violations can be life-threatening. Private single-family resi- dential swimming pools are not subject to annual safety inspections by the city but can be inspected when requested by the owner. These pools were excluded from our study. Our study did not involve human subjects. Patients or the public were not involved in the design, conduct, reporting, or dissemina- tion plans of our research. Inspection Data Inspection data of all registered commercial swimming pools within the city limits of Houston were obtained from the Houston Health Department (HHD). Data included name and address of the property where the pool was sited, housing type (e.g., apartment, spa, city pool, club, condominium, commu-
TABLE 1
Comparison of the Model Aquatic Health Code (MAHC) and City of Houston Safety Codes and Violation Points
Safety Code
MAHC Violation Points
City of Houston Violation Points
Pool and spa
Enclosure in good repair
10 10 10
10 10 10
Self-closing/self-latching gates Protected overhead electrical wires
Grab rails, ladders secured; shell, deck in good repair
5 5 5 5
5 5 5 5
Float/safety line clearly present
Depth and no diving markers; stair stripes; in good repair and visible Skimmers: weirs and baskets installed; clean and operating; covers in good repair
Recirculation inlets functional
5
5
Main drain grate secured in place and in good repair
10 10
10 10
Water is clear, main drain visible
Starting blocks removed, covered, or access blocked Pool deck free from obstructions; emergency exit marked Emergency phone or other communication device available and well-marked
5 5 5
5 5 5
First aid kit available
5
5
Appropriate safety equipment present and in good repair
10 10
10
Adequate supervision of the facility
*
Signs: bathing load, rules, chemicals, and spa legible and in good repair
5
5
Spa temperature ≤104 ºF (40 ºC)
10
10
Water chemicals Approved NSF/ANSI Standard 50 DPD test kit
5
5
Proper disinfectant level pH between 7.2 and 7.8 Combined chlorine <0.4 ppm
10 10
10 10
5 5
* *
Cyanuric acid ≤100 ppm
continued on page 10
few other counties and states have adopted the MAHC (Hlavsa et al., 2016). The City of Houston, Texas, has not adopted the MAHC and instead uses a Code of Ordinances to reg- ulate the safety of city swimming pools (City of Houston, 2023). The primary aim of our study was to develop a grading system for swimming pool safety for Houston by applying the MAHC to city swimming pool inspection data. We hypothesized that by using a safety grading
system for public aquatic facilities, it would be possible to disseminate swimming pool safety information to guide injury-prevention measures and inform pool operators and the public about problematic pools.
Methods
Study Design and Setting We conducted a cross-sectional study of swimming pool safety inspection data for
9
July/August 2023 • <B?;.9 <3 ;C6?<;:2;A.9 2.9A5
ADVANCEMENT OF THE SCIENCE
nity association, fitness club, hotel, hospital, nursing home, mobile home, park, school, day care), and publicly available information on swimming pool violations per the Code of Ordinances for Houston. Data obtained from HHD also included pool addresses. In some cases, the addresses that were provided were the establishment’s parent company that was located outside Houston or were post oce boxes rather than the physical location of the swimming pool. The addresses of these swimming pools were traced from their respective HHD swimming pool accounts. In total, seven swimming pools did not have associated addresses or a corresponding active account with HHD; these pools were excluded from our analy- sis. Swimming pool addresses were converted to longitude and latitude coordinates, geo- graphically coded using Texas State Plane Southcentral NAD 83 (a projection system used by most government agencies in the region), and projected onto a map of Houston using ArcGIS Pro version 2.5.0. Application of the MAHC to Swimming Pool Safety Violation Codes The MAHC codifies aquatic safety inspec- tion items and includes an inspection form to grade the safety of swimming pools against RWIs (CDC, 2018a, 2018b). The inspection form consists of 49 inspection items based on safety, chemical, and health hazards. The safety categories on the inspection form per- tain to the pool and spa area, water chemi- cals, equipment and chemical room, hygiene facilities, records room, and general items. Within each category are subitems that are assigned points. Points are deducted from subitems that are not in compliance with code after a pool inspection is performed. Overall, 13 of the MAHC compliance items are deemed critical for passing swimming pool inspections because noncompliance can be potentially life-threatening. Swimming pools are assigned safety grades based on the proportion of subitems that have passed inspection (expressed as a percentage). A swimming pool receives a failing grade if the percentage of subitems that pass inspection is <75% or if there is a critical violation that can be life-threatening (CDC, 2018a). HHD inspects 29 items for safety violations during routine swimming pool inspections. These items are referenced by their correspond-
Comparison of the Model Aquatic Health Code (MAHC) and City of Houston Safety Codes and Violation Points TABLE 1 continued from page 9
Safety Code
MAHC Violation Points
City of Houston Violation Points
Equipment and chemical room Automated feeder operable
10
10
Automated controller operable
5 5 5
*
Piping and valves identified and marked
5 5
Flow meter present and operating
Recirculation pump: approved, in good repair, operating
10 10
10 10
Filter: approved, in good repair, operating
Pump strainer: baskets in good condition, not clogged
5 5 5
5 5
Filter gauges operable: filter inlet and outlet, strainer; sight glass
Proper functioning UV system; ozone system Chemicals: labeled, stored safely, secured Appropriate personal protective equipment available
*
10
10
5
*
Hygiene facilities Diaper changing station present; sink, adjacent trash can, sanitizer
5 5 5 5 5 5 5 5 5 5 5 5 5
* * * * *
Used equipment separated from clean equipment
Toilets: clean, in good repair, bathroom appropriately stocked
Rinse showers: in good repair, accessible
Cleansing showers: warm, nonscalding water available; in good repair; soap
Records room Operator training certification available on-site Lifeguard training certification available on-site
5
Inspection report conspicuously posted at each entrance Operator inspection daily items: checklist used daily Operator inspection items: evidence of appropriate steps promptly taken
* * * * * *
Chemical records: filled out daily
Chemical records: evidence of appropriate steps promptly taken
Emergency action plan available on-site
General Substantial unauthorized alterations/equipment replacement Other: imminent health hazards are a 10-point critical violation
10
* *
5 or 10
* Indicates items that the City of Houston does not inspect. Note. Bolded items represent critical code items in the MAHC.
ing code in the Code of Ordinances for Hous- ton. We reviewed the MAHC with HHD sta to determine which of the 49 safety items on the MAHC were in use by Houston during their
swimming pool inspections. HHD confirmed using 29 of 49 MAHC items and 11 of the 13 critical items in the MAHC. Moreover, there are additional subcodes in use by HHD that match
10
+<9B:2 • $B:/2?
cal element regardless of the total score. Table 1 describes the 49 items in the MAHC, with the matching 29 items used by HHD during swimming pool inspections. Table 2 describes the subsection of the statutes used in the HHD code and its matching MAHC item. We used descriptive statistics to describe pool violation data. SAS version 9.4 was used to group, analyze, combine items, and apply inspection data to the MAHC. All 2016 inspections and violation data from Houston were merged by unique identifiers in both data sets. Data were queried on active estab- lishment status, nonabatement license status, and annual routine inspections. If a pool had more than one routine inspection, then the first date of inspection was selected. Violation codes were grouped into 29 categories with a score assigned to each violation group. Results There were 3,107 swimming pools inspected in Houston in 2016. Of these, 3,100 had addresses and accounts located within the city limits of Houston; a total of 7 pools had addresses that were not in the city limits or had a post oce box listed and no current account associated. Table 3 describes the safety grades for swim- ming pool establishments based on the MAHC with 79.2% of the pools located in multifam- ily establishments. The second-most common type of establishment were pools located in hotels or motels (10.5%). Two swimming pools did not have a listed establishment. As shown in Table 3, the safety grading process resulted in 1,246 (40.2%) swimming pools with an A grade, 15 (0.5%) pools with a B grade, 0 pools with a C grade, and 1,839 (59.3%) pools with an F grade. Of the 1,839 pools that received an F grade, 14 (<1%) obtained their failing grade based on a failing overall percentage. The remainder of pools with failing grades were noncompliant with ≥1 critical safety item in the MAHC. Table 4 demonstrates the frequency of the pool violations for each of the 29 items in the MAHC that were observed during inspec- tions in Houston. Violations related to swim- ming pool enclosures were the most frequent, with 729 violations (18.0%), followed by 558 violations (13.8%) related to self-closing or self-latching gates. The third-most common violation was related to disinfectant levels (516, 12.7%). Application of the city code inspection criteria resulted in 1,285 swim-
TABLE 2
City of Houston Swimming Pool Violation Codes With Matching Model Aquatic Health Code (MAHC) Items
MAHC Item
City of Houston Swimming Pool Violation Code
Pool and spa
Enclosure in good repair
25 TAC §265.200, HSC 757.00, HSC 757.005 25 TAC §265.200, HSC 757.004
Self-closing/self-latching gates Protected overhead electrical wires
25 TAC §265.192 25 TAC §265.186 25 TAC §265.199 25 TAC §265.199
Grab rails, ladders secured; shell and deck in good repair
Float/safety line clearly present
Depth and no diving markers; stair stripes; in good repair and visible Skimmers: weirs and baskets installed; clean and operating; covers in good repair
25 TAC §265.191
Recirculation inlets functional
25 TAC §265.191
Main drain grate secured in place and in good repair
25 TAC §265.190, Sec 1404
Water is clear, main drain visible
25 TAC §265.203 25 TAC §265.186 25 TAC §265.186 25 TAC §265.199
Starting blocks removed, covered, or access blocked Pool deck free from obstructions; emergency exit marked Emergency phone or other communication device available and well-marked
First aid kit available
25 TAC §265.199 25 TAC §265.199
Appropriate safety equipment present and in good repair
Adequate supervision of the facility
N/A
Signs: bathing load, rules, chemicals, and spa legible and in good repair
25 TAC §265.205
Spa temperature ≤104 ºF (40 ºC)
25 TAC §265.205
Water chemicals Approved NSF/ANSI Standard 50 DPD test kit
Sec 43-4(b)
Proper disinfectant level pH between 7.2 and 7.8 Combined chlorine ≤0.4 ppm
25 TAC §265.204 25 TAC §265.204
N/A N/A
Cyanuric acid ≤100 ppm
continued on page 12
some of the 29 items that are common with the MAHC and HHD inspection forms. The 20 items in the MAHC that do not have a corresponding HHD code were not included for analysis and were listed as “not applicable.” Items in the MAHC are scored 5 or 10 points; critical items carry a higher value of 10 points. We used the same scor- ing in the MAHC for the corresponding HHD safety items. All 49 inspection items in the MAHC inspection form are not required
to generate a complete score; an option for “not applicable” is available (CDC, 2018a). Based on this scoring, the maximum number of compliance points possible after an HHD swimming pool inspection is 210. Letter grades were calculated as total com- pliance points scored after an inspection divided by the maximum possible compli- ance points. Letter grades were classified as: A = 95–100%; B = 85–94%; C = 75–84%; and fail (F) = <75% or noncompliance of a criti-
11
July/August 2023 • <B?;.9 <3 ;C6?<;:2;A.9 2.9A5
ADVANCEMENT OF THE SCIENCE
ming pools that failed safety inspection (30% less) compared with 1,839 pools that would have failed based on applying the MAHC. Figures 1 and 2 demonstrate the spatial distribution of swimming pools in Houston based on their safety grades. Most swimming pools, irrespective of the degree of pool safety violations, were located in the Southwest sec- tion of Houston. Discussion In this study, we applied the MAHC inspec- tion checklist to Houston pool violation data to grade swimming pools for safety in a jurisdiction that has not adopted the MAHC. The safety grading of commercial swimming pools revealed that pool safety violations were widespread, with more than one half of the pools receiving a failing grade. In almost all cases, the cause of the fail- ing grade was a critical violation that could have been life-threatening if not corrected. The majority of swimming pools that failed inspection occurred in multifamily establish- ments. A prior study in Harris County, Texas, for which Houston is the county seat, found that out of 196 unintentional drownings, one half occurred in multifamily residential pools (Warneke & Cooper, 1994). Another study in the same region revealed that pediatric drownings are 28 times more likely in a mul- tifamily swimming pool than a single-family pool (Shenoi et al., 2015). We observed that the most common safety violations were due to faulty swimming pool enclosures, gates and safety equipment, and improper disinfectant levels. Swimming pool chemical violations also occurred fre- quently. Our results are consistent with the high incidence of faulty pool enclosures and improper levels of pool chemicals docu- mented on pool inspections conducted else- where in the U.S. Documenting the magni- tude of pool violations and the number of RWIs is a first step toward advocating for improved legislation and enforcement of swimming pool safety regulations. Additionally, data from 15 jurisdictions found that pool chemical violations were pres- ent in 10.7% of pool inspections (CDC, 2010). Hlavsa et al. (2016) described similar results with disinfectant concentration violations and pool chemical safety violations, which were identified in 11.9% and 4.6% of routine inspec- tions, respectively. These findings are impor-
City of Houston Swimming Pool Violation Codes With Matching Model Aquatic Health Code (MAHC) Items TABLE 2 continued from page 11
MAHC Item
City of Houston Swimming Pool Violation Code
Equipment and chemical room Automated feeder operable
25 TAC §265.197, 25 TAC §265.204
Automated controller operable
N/A
Piping and valves identified and marked
25 TAC §265.187 25 TAC §265.187 25 TAC §265.189 25 TAC §265.188 25 TAC §265.189
Flow meter present and operating
Recirculation pump: approved, in good repair, operating
Filter: approved, in good repair, operating
Pump strainer: baskets in good condition, not clogged Filter gauges operable: filter inlet and outlet, strainer; sight glass Proper functioning UV system; ozone system Chemicals: labeled, stored safely, secured Appropriate personal protective equipment available
25 TAC §265.187, 25 TAC §265.188
N/A
25 TAC §265.197
N/A
Hygiene facilities Diaper-changing station present; sink, adjacent trash can, sanitizer
N/A N/A N/A N/A N/A
Used equipment separated from clean equipment
Toilets: clean, in good repair, bathroom appropriately stocked
Rinse showers: in good repair, accessible
Cleansing showers: warm, nonscalding water available; in good repair; soap Records room Operator training certification available on-site Lifeguard training certification available on-site Inspection report conspicuously posted at each entrance Operator inspection daily items: checklist used daily Operator inspection items: evidence of appropriate steps promptly taken
N/A
25 TAC §265.199
N/A N/A N/A N/A N/A N/A N/A N/A
Chemical records: filled out daily
Chemical records: evidence of appropriate steps promptly taken
Emergency action plan available on-site
Substantial unauthorized alterations/equipment replacement Other: imminent health hazards are a 10-point critical violation
Note. Bolded items represent critical code items in the MAHC. HSC = Texas Health and Safety Code; N/A = not applicable; TAC = Texas Administrative Code.
tant because the median estimated number of persons visiting emergency departments for chemical-related injuries from pools was 4,247 per year between 2003 and 2012 (Hlavsa et al., 2014). Identifying these violations and enforc- ing corrective action can mitigate the risk of swimming pool chemical-related injuries.
We also observed that faulty swimming pool enclosures and gates and inappropriate safety equipment were the most common vio- lations found during routine pool inspections. Many of these violations resulted in immediate pool closure. This finding is similar to another study where pool enclosure violations and
12
+<9B:2 • $B:/2?
inappropriate safety equipment were identi- fied in 5.1% and 12.7% of pool inspections, respectively (Hlavsa et al., 2016). It is known that isolation swimming pool fences reduce the risk of drowning (Thomp- son & Rivara, 1998). As such, the American Academy of Pediatrics recommends a mul- tilayered approach to reduce drowning that includes functioning isolation swimming pool fencing and self-latching and self-clos- ing gates (Denny et al., 2021). We found that pool safety inspections in Houston, as currently conducted, captured 30% fewer swimming pool violations than if the MAHC criteria were used. Almost all of the safety violations observed were indi- vidual violations and <1% of the swimming pools that failed did so because of a low overall score. Many of the items that are not listed in the code used by Houston but that appear in the MAHC pertain to facility hygiene, record- keeping, and unauthorized alterations or replacement of equipment. Except for the lat- ter, which could be potentially dangerous, the first two items pertain to maintaining a clean facility to reduce the transmission of illness and disease and implementing proper aquatic management practices. Other reasons for not including these MAHC items could be that inspections are conducted based on the basic and common certification requirements and therefore these less common requirements might be neglected (National Association of County and City Health Ocials, 2015). Implications Our results have the following implications. Recreational water safety is regulated at the state or local level, and thus there is wide variation in implementing policy and safety practices across jurisdictions. Houston might need to update its inspection criteria to cur- rent MAHC standards and institute best prac- tices for pool safety. There has been a marked increase in rec- reational use of residential and public dis- infected water as leisure time around the pool has increased. Changes in the design of aquatic facilities have occurred and regulatory agencies need to keep abreast of these changes. A legislative approach that includes instituting updated versions of the MAHC would be one solution. There are fiscal implications, how- ever, that will also need to be evaluated.
TABLE 3
Swimming Pool Safety Grades by Establishment After Applying the Model Aquatic Health Code
Establishment
Swimming Pool Safety Grades # (%)
A
B
C 0 0 0 0 0 0 0
F
Total
Multifamily
951 117
14
1,491
2,456 (79.2)
Hotel or motel
1 0 0 0 0 0 0
206
324 (10.5)
Health or fitness facility
52 34 55 25
47 42 20 26
99 (3.2) 76 (2.5) 75 (2.4) 51 (1.6) 13 (0.4)
Club
City or public facility School or day care
Healthcare facility
8 4
5 2
Other
0
6 (0.2) 3,100 (100)
Total
1,246 (40.2)
15 (0.5)
0 (0)
1,839 (59.3)
Note. A = 95–100%; B = 85–94%; C = 75–84%; and F = <75% or noncompliance of a critical element regardless of the total score.
TABLE 4
Frequency of Observed Swimming Pool Violations
Item From the Model Aquatic Health Code (MAHC) Inspection Form Observed by the City of Houston
Observed Violations # (%)
Pool and spa
Enclosure in good repair
729 (18.0) 561 (13.8)
Self-closing/self-latching gates Protected overhead electrical wires
56 (1.4) 34 (0.8)
Grab rails, ladders secured; shell and deck in good repair
Float/safety line clearly present
0 (0)
Depth and no diving markers; stair stripes; in good repair and visible Skimmers: weirs and baskets installed; clean and operating; covers in good repair
136 (3.4)
24 (0.6)
Recirculation inlets functional
0 (0)
Main drain grate secured in place and in good repair
244 (6.0)
Water is clear, main drain visible
88 (2.2)
Starting blocks removed, covered, or access blocked Pool deck free from obstructions; emergency exit marked
5 (0.1)
1 (0.02)
Emergency phone or other communication device available and well-marked
151 (3.7)
First aid kit available
0 (0)
Appropriate safety equipment present and in good repair Signs: bathing load, rules, chemicals, and spa legible and in good repair
374 (9.2)
88 (2.2)
Spa temperature ≤104 ºF (40 ºC)
7 (0.2)
continued on page 14
13
July/August 2023 • <B?;.9 <3 ;C6?<;:2;A.9 2.9A5
ADVANCEMENT OF THE SCIENCE
These changes would involve training cur- rent safety inspectors and using an incremental approach to allow regulatory and industry part- ners to adapt to changing MAHC guidelines. CDC (2023b) provides resources for public healthocialsandaquaticsta toimple- ment MAHC recommendations or strengthen their aquatic health and safety programs. The advantages of incorporating MAHC guidelines would be use of the most e ective water safety inspection criteria, which could translate into reduced RWIs. Furthermore, inspection results could be compared with other jurisdictions that use similar inspection criteria. A promising aspect of our study is the ability to illustrate the distribution of swim- ming pools in Houston based on their safety grade. This mapping has potential use in injury prevention. This approach has been used in playground safety, where the safety scores of playgrounds in need of maintenance were spatially mapped in Chicago to e ect improvements in fall surfacing and equip- ment maintenance (Allen et al., 2013). The same approach could be applied to swimming pool safety in Houston. Cur- rently, Houston maintains an up-to-date list- ing of all pool violations by property that is accessible to the public (Houston Health Department, 2023b). The City of Plano, Texas, employs a similar scoring system that allows the public to look up swimming pools with color-coded scores that show the results of the swimming pool inspection (Plano Health Department, n.d.). Data from our study demonstrate that the swimming pools that failed safety inspections were predominantly concentrated in South- west Houston, which has a larger percentage of residents belonging to a lower socioeco- nomic status (City of Houston Planning & Development Department, 2016a) and racial and ethnic minority groups (City of Hous- ton Planning & Development Department, 2016b). The rate of unintentional drown- ings is higher in children belonging to racial and ethnic minorities (Felton et al., 2015; Gilchrist & Parker, 2014), which could serve as a focus for injury prevention e orts to reduce drowning. Limitations There are several limitations to our study. First, our findings are not generalizable to other jurisdictions that have other types of
Frequency of Observed Swimming Pool Violations TABLE 4 continued from page 13
Item From the Model Aquatic Health Code (MAHC) Inspection Form Observed by the City of Houston
Observed Violations # (%)
Water chemicals Approved NSF/ANSI Standard 50 DPD test kit
2 (0.05)
Proper disinfectant level pH between 7.2 and 7.8 Equipment and chemical room Automated feeder operable
516 (12.7) 449 (11.1)
99 (2.4)
Piping and valves identified and marked
238 (5.9) 126 (3.1)
Flow meter present and operating
Recirculation pump: approved, in good repair, operating
38 (0.9)
Filter: approved, in good repair, operating
8 (0.2)
Pump strainer: baskets in good condition, not clogged
1 (0.02) 74 (1.8) 1 (0.02)
Filter gauges operable: filter inlet and outlet, strainer; sight glass
Chemicals: labeled, stored safely, secured Records room Lifeguard training certification available on-site
2 (0.05)
Note. Bolded items represent critical code items in the MAHC.
FIGURE 1
Location of Swimming Pools in the City of Houston That Received A Grades
Note. Shaded area indicates the City of Houston.
14
Volume 86 • Number 1
Conclusion The strength of our study is that our meth- odology could be used by other jurisdictions that have not adopted MAHC criteria yet. If used across jurisdictions, our approach can ensure consistency in swimming pool safety grading. Future directions include evaluating if safety issues with swimming pools persist in subsequent years, investigating prevailing socioeconomic and health disparities in areas with a high concentration of pools that fail safety inspections, and developing an online platform that is available to the public that could host a map of swimming pools by safety grade. Overall, the MAHC can be applied to grade swimming pool safety in jurisdictions where it has not yet been adopted. The degree of safety violations can be spatially demon- strated (e.g., mapped) to inform injury-pre- vention measures. Acknowledgements: We gratefully acknowl- edge Kenneth Malveaux and Naomi Macias of the Commercial/Residential Pool Program within the Houston Health Department for providing us with pool inspection data and their insight on swimming pool inspections. We also acknowledge Ryan Ramphul for his help with geographical mapping of the swim- ming pools. Corresponding Author: Rohit P. Shenoi, Divi- sion of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, 6621 Fannin Street, Suite A2210, Houston, TX 77030. Email: rshenoi@bcm.edu.
FIGURE 2
Location of Swimming Pools in the City of Houston That Received F Grades
Note. Shaded area indicates the City of Houston.
aquatic bodies and permitting agencies. For example, we did not study pool violations in single-family homes, as they are not sub- ject to annual safety inspections. Second, we included only 1 year of data. It would, however, be preferable to include additional years of data to assess safety trends. Third, some swimming pools that failed safety inspection might have corrected their defi- ciencies after the routine inspection. Thus,
we were unable to determine if the safety deficiency was long-standing. It is highly likely, however, that the safety concerns were addressed in a timely manner because the property managers would want to open the aquatic facility to their clients at the earliest possible point. Finally, we can- not comment on aboveground or portable swimming pools, as they are not subject to safety inspections.
References
Allen, E.M., Hill, A.L., Tranter, E., & Sheehan, K.M. (2013). Play- ground safety and quality in Chicago. Pediatrics , 131 (2), 233–241. https://doi.org/10.1542/peds.2012-0643 Centers for Disease Control and Prevention. (2010). Violations identified from routine swimming pool inspections—Selected states and counties, United States, 2008. Morbidity and Mortality Weekly Report , 59 (19), 582–587. Centers for Disease Control and Prevention. (2018a). Model Aquatic Health Code facility inspection report (CS300555-A). https://www. cdc.gov/mahc/pdf/MAHC-Form-2019-508c.pdf Centers for Disease Control and Prevention. (2018b). 2018 Model Aquatic Health Code: Code language (3rd ed., CS288986-A). https://www.cdc.gov/mahc/pdf/2018-MAHC-Code-Clean-508.pdf
Centers for Disease Control and Prevention. (2023a). The Model Aquatic Health Code (MAHC): An all-inclusive model public swim- ming pool and spa code . https://www.cdc.gov/mahc/index.html Centers for Disease Control and Prevention. (2023b). The Model Aquatic Health Code (MAHC): An all-inclusive model public swim- ming pool and spa code—MAHC tools and training . https://www. cdc.gov/mahc/networks-tools-forms.html City of Houston. (2023). Code of Ordinances: Chapter 43—Pool and spa safety . https://library.municode.com/tx/houston/codes/ code_of_ordinances?nodeId=COOR_CH43POSPSA City of Houston Planning & Development Department. (2016a). 2016 median household income . https://www.houstontx.gov/plan ning/Demographics/docs_pdfs/2016acsd/Median-HHI.pdf
continued on page 16
15
July/August 2023 • Journal of Environmental Health
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50 Page 51 Page 52 Page 53 Page 54 Page 55 Page 56 Page 57 Page 58 Page 59 Page 60Powered by FlippingBook