Safer Waters for All

MAHC Created to Improve Pool Safety

By Deborah L. Vence

Public pool facilities and spas in the United States now have a new resource to turn to if they want to improve their existing pool codes.

The Model Aquatic Health Code (MAHC)—the first edition of which was released Aug. 29, 2014—is a guidance document that jurisdictions can use to update or implement codes, rules, regulations, guidance, laws or standards governing swimming pools, spas, hot tubs and other public, treated, recreational water venues to reduce infectious disease outbreaks, drowning and chemical injuries.

"In a perfect world, the whole goal is to have consistency across the country with the most up-to-date science and data and supporting requirements. Ultimately, the goal is [for the MAHC] to be in effect across the country, states, counties and cities. That would be the ideal outcome of this," said Doug Sackett, executive director of the Conference for the Model Aquatic Health Code (CMAHC), which was created in 2013 to serve as a national clearinghouse for input and advice on needed improvements to the MAHC.

Currently, no federal agency regulates the design, construction, operation and maintenance of public swimming pools and other public, treated, recreational water venues. All pool codes are written and enforced independently by state and local agencies. In 2005, though, local, state and federal public health officials and representatives of the aquatic sector requested that the Centers for Disease Control and Prevention (CDC) develop a model, evidence-based code.

Currently, no federal agency regulates the design, construction, operation and maintenance of public swimming pools and other public, treated, recreational water venues.

"One of the first things is that it's not a factor enforced until a local jurisdiction adopts it. Until a health department adopts it, it's not enforceable," Sackett explained. "We also recognize that local issues [might arise], and some jurisdictions may adopt portions of it. Operationally, they might have some nuances. And, some might not adopt any of it."

Furthermore, although the MAHC is deemed a code, it still is not "technically a code itself," but rather a "model or proposed code," noted Richard K. Cacioppo, Sr., J.D., a trial and appellate constitutional lawyer, and president and CEO for the Institute for Advanced Marketing for the pool industry.

"The CDC has no power or authority to enforce a single provision, and is not permitted by law to lobby for its passage. It does recommend that all public pools be regulated in a far stricter manner," he said. "[The MAHC] only replaces what each individual state and local health code currently has in place, some provisions in full and others in only a small way. No present code will be affected unless and until the regulatory agency that enacts local and state laws adopts any portion of it. Nothing changes until then."

Waterborne Illnesses

Increasing outbreaks of Cryptosporidium, a recreational water illness that has been on the rise in recent years and prompted discussion for the MAHC in 2005, should be a big enough reason for local health departments to consider adopting the code, or at least parts of it.

Crypto is a chlorine-tolerant parasite and can survive for days in a well-chlorinated pool. The MAHC suggests facilities use additional secondary disinfection safeguards, such as ultraviolet light or ozone, which kills crypto, particularly for increased-risk aquatic venues, such as children's wading pools and splashpads.

"The increase in waterborne illness along with increased injuries and drowning events at public aquatic facilities led to the need for improved and unified public health programs. The main intent was to address some very specific risk and new threats that may not have been pertinent at the time that many local codes were written," said Terry Arko, recreation water specialist for a clean water technology company based in Bothell, Wash., and a certified pool operator (CPO) and a CPO course instructor through the National Swimming Pool Foundation (NSPF).

"It was pretty much the increase of outbreaks at recreation water facilities [that led to its creation]," Sackett said. "The code basically has three sections, [including a] design section. It has all of the design, filter, secondary disinfectant [information] … how you operate it, what are the chlorine levels, what staffing do you need. There is a move toward a requirement in the code for secondary disinfection for those higher-risk venues. That's another important thing to know. How does this impact me?" Sackett said.

Moreover, design criteria are written in the MAHC that inform facilities how to handle remediation. If, for example, a facility does not have UV to eradicate crypto, there is a design criterion written in the code that explains how to fit it in.

The MAHC stresses the importance of UV by stating that "the rate of chlorine loss (pounds of chlorine per hour) due to UV degradation will depend on a number of factors, including the size of the aquatic venue, the depth of the water and the intensity of the sunshine. It will also depend on the concentration of cyanuric acid present, since cyanuric acid can help prevent the decomposition of chlorine by UV …."

What to Know About the MAHC

The new code brings a set of voluntary guidelines that are based on science and best practices to be a unifying standard for those who regulate public recreational water facilities.

"Its primary purpose is to serve as a means to reduce the risk of disease, injury and drowning at aquatic facilities nationwide," Arko said.

"One of the issues we have here is that aquatics is the national pastime," said Michael Beach, associate director for Healthy Water, National Center for Emerging and Zoonotic Infectious Diseases, CDC. "There are hundreds of thousands of visits every year, 365 days a year, as it moves indoors each year," thus increasing the risk even more for drownings and waterborne illnesses.

"We want people to become aware and understand the issues. This is all aquatic venues treated with recirculated water. It's the venue … everything that is encompassed is covered in this code. From the aquatic operator standpoint, you need to understand that many of the larger changes are larger constructions for bigger venues," Beach said.

For instance, for a diaper changing station, it shouldn't just be something that you strap on to the wall in a locker room. Ideally, there should be a separate changing area in locker rooms so parents can change their babies' diapers in a sanitary environment.

The goal is for the minimum standard to be raised, for people who don't operate their facilities as well as they should.

"We want to see that group moved up," Beach asserted.

Furthermore, Cacioppo added that pool operators should become familiar with all of the main topics of the MAHC, as well as many of the subtopics.

"But, it is very subjective what is more important and what is less important," he said. "I personally believe cleaning (vacuuming and brushing) is vital, yet the code makes no reference at all to this subject. It does propose regulations on other things that many would consider insignificant."

Moreover, Cacioppo argued that the code, 316 pages long and the annex another 371 pages, "is far too lengthy and detailed to ever be as effective as it may have been had it concentrated at first only on essential elements of health and safety," he said. "I believe the committee took seven years to complete the code which they originally planned to do in three because, in part, it is simply too complex."

Cacioppo, who also is the CEO and executive director of the Center for Public and Lodging Pool Studies, Princeton, N.J., believes that the MAHC addresses some very minute issues, too, such as specifics of the height of fences and flow rates to protect piping.

"It was intended when it was first proposed in 2005 to address the growing threat of Cryptosporidium, but as you can see if you just look at the Table of Contents, it includes a Glossary, and sections on Facility Design and Construction, Policies and Management, and other regulations that are only indirectly related to direct health issues," he said.

The goal is for the minimum standard to be raised, for people who don't operate their facilities as well as they should.

While there might be differing opinions on the effectiveness of the new code, the Multnomah Athletic Club, a private not-for-profit athletic and social club near downtown Portland, Ore., wants to adopt as much of the new aquatic code as it can. For many of the items, though, the club already is in compliance, such as lifeguard coverage and mechanical specs.

"I printed it out … and we are adopting it. We are pretty well situated, though, because we have a healthy budget," said Lisa Virtue, aquatics manager at the club.

"We have three pools with backup help. We have supervisors on every hour that we are open, an aquatic [supervisor] or manager on duty. As far as lifeguard coverage, I do know that private clubs will struggle with that. We don't have to provide lifeguards, but we choose to," she said.

For lifeguard coverage, as pool managers go, the main issue is money. There are other clubs that don't provide lifeguards, choosing to avoid that expense.

"From the facility side," Virtue said, "we are pretty up to date. We have UV in all of our pools; pumps that run appropriately; air-handler units. And we updated everything in there."

To boot, "Our local health official has been great about talking to us, with the operators, [and asking] what is your opinion on this. That's been fantastic," she said.

At Multnomah, at least four lifeguards are on duty at its three pools, and rotate every 30 minutes, with a supervisor and coordinator on duty as well.

"Right now, there is no reason to do the code unless you are building a new facility. But, personally, if I would build a pool, I would look at the MAHC," she said.

A Team Effort

To help make the MAHC possible, technical committees were created to work specifically on the code. And, since 2007, the CDC has led a national collaborative effort with public health, industry and academic representatives from across the United States to develop the MAHC, which is available online at the CDC website, www.cdc.gov.

Designers, public comment and the input of 150 industry experts were part of the MAHC's establishment.

"This is basically the outcome from state, academics working together and coming up with model guidance," Beach said.

"Everyone was involved in this. It was developed by a technical committee," Sackett added. "So, we would have public comment, and then once it had those revisions, [they would] meld it into one document, the whole blended version. We looked at those proposals. We had over 4,000 public comments, and about 72 percent were incorporated. Posted on the web, the draft version was on the web. There is a public forum and anybody out there reviewing the code … here's the section and here's why we'd like to change, providing the rationale."

A number of volunteer teams made up of health officials, scientists and recreational water professionals contributed to the MAHC.

"It has been peer-reviewed and revised prior to the initial publication. The main intent of the document is to serve as an all-encompassing health and safety document," Arko said.

"We feel that it really has a lot of merit," Sackett said. "It incorporates the best possible practices. The annex is a parallel document. It's the 'why' behind the 'what.' What data was looked at? How it came to that code section."

"The nicest thing about the MAHC is that it gives you the code in code language. In the annex it gives you the rationale and why they came up with the code," noted Tom Griffiths, president and founder of the Aquatic Safety Research Group, LLC. "It educates the reader so they would be more knowledgeable when they have to make a decision. It gives you all of that information. I think of the MAHC as an encyclopedia of best practices."

The CMAHC

Water treatment today is about how facilities provide a cleaner, safer and more enjoyable experience for patrons, all while using less chemicals and wasting water.

To keep the MAHC updated every two years, a special committee called the Conference for the Model Aquatic Health Code (CMAHC) was formed.

Every two years the CDC will work with national partners to update the MAHC to ensure that it stays current with the latest industry advances and public health findings. CMAHC members will suggest MAHC revisions for the CDC's final determination.

While the MAHC is owned by the CDC and resides on its website, "What we did was set up a nonprofit corporation to be the source, to gather input and provide feedback and input on the code. Things evolve quite rapidly, and there is more research that needs to be done; to keep it up to date and current. We wanted to update it routinely," Sackett said.

Drowning Prevention

Continued efforts to prevent drownings center on the fact that swimming pools simply don't only have rectangular shapes anymore, but rather, more free-form shapes—thus increasing the likelihood for blind spots in pools.

When building a new facility, pool operators should bear in mind the shape of the pool, and not have to find out until it's too late that there are obstructions, experts say.

Sackett suggests that facilities "Work collaboratively with water safety experts and have an understanding on how to properly supervise from a lifeguard standpoint."

Then there's the importance of glare, too.

While natatoriums might have beautiful light, for lifeguards it can be a nightmare when there's glare on the water's surface. So, the basic concept is to address the potential for glare and compensate for that.

"Every area of supervision can be adequately seen in an appropriate amount of time, every facility and staffing plan. And, staff has the zones of coverage so the guard has the ability to reach a person in distress. That's built into the code," Sackett explained.

"There is a significant amount of pools out there that don't have guards. For new construction, anything over five feet needs a lifeguard," he said.

The new code covers drowning prevention in a multitude of ways.

For instance, "We have required that if someone is going to build a facility, [they should have a consult] and have an aquatics expert on board," Sackett said.

Connie Harvey, director, Aquatics Centennial Initiatives at the American Red Cross in Washington, D.C., said the biggest thing that's happening is that everybody understands that there are layers of protection in preventing drownings.

"There is a lot of effort in different initiatives that highlight and make those or provide access to those layers of protection," she said. "When we talk about our Centennial campaign, the learn-to-swim aspect is important, but others are just as important, including water safety education for partners and caregivers."

For example, choices have to be made and a level of supervision has to take place on whether or not to put a child in a life jacket.

"So, that is a critical piece of it; to make parents and caregivers [be a part of] the prevention side. But, then the swimming lessons are a critical piece to it all. Also, there's what to do in the event something goes wrong. Inviting parents to teach them how to help themselves in the water and what kind of equipment you should have on hand," Harvey said.

Moreover, facilities are tackling drowning prevention by offering a one-week session of lessons. They know that children need to know how to swim. And, some facilities are using special bands that children can wear on their wrists to distinguish which children know how to swim and which ones don't. Some are even opting to do a swim test to see how well they are able to swim.

"What we have defined as water competency, [if someone] has the green band it allows them to swim in the deeper end. Someone in the red band is required to stay in the shallow end of the water. Many YMCAs do that as well," Harvey said.

"A lot of facilities are starting to adopt our definition of water competency," she added.

For example, the testing might involve having to float on your back or tread water, and be able to orient in a complete circle and swim 25 yards. Also, you have to be able to get into a pool and get out without using a ladder.

"There is a sequence of skills [to show] that someone can handle themselves in the water," she said.

Also, Harvey discussed the Red Cross' Circle of Drowning Prevention, which states the following:
  • Provide close and constant attention to children you are supervising in or near water.
  • Fence pools and spas with adequate barriers, including four-sided fencing.
  • Learn swimming and water safety survival skills.
  • Children, inexperienced swimmers and boaters should wear U.S. Coast Guard-approved life jackets.
  • Always swim in a lifeguarded area.

Griffiths added that it is equally important to make sure everyone at a pool is aware of non-swimmers.

"We really push situational awareness in making everyone in the facility aware of the non-swimmers. And what many pools do, even if they don't require the life jacket, they either use very attractive quick-release necklaces for intermediate swimmers and non-swimmers, or bands on the wrist, which allows parents to immediately know what ability level that child is at," Griffiths said.

In fact, anecdotal evidence shows that younger kids become interested in wanting to learn how to swim in order to join their older siblings in deeper water or measure up to their brother or sister's swimming ability.

"We find out that with life jackets and identifying marks, swim lesson enrollment increases. They want to move up to the next color band or get out of the life jacket, and it moves kids along," he said.

Moreover, "Water clarity standards along with additional lifeguard staff are just a couple of the ways to ensure less drowning events," Arko added. "Breath-holding games have been responsible for many drowning situations and injuries at public pools. This practice is now forbidden at most public recreational water sites."

Water Treatment

The recognition of the value of secondary treatment methods is a trend seen more often now in water treatment.

"From a commercial aquatic standpoint, these secondary methods come in the form of UV, ozone and enhanced filtration with polymers," said Brian Bokowy, business manager CIM for a provider of chemicals to the swimming pool and spa markets.

"When used in conjunction with proper chlorination techniques and good maintenance practices, these methods serve to reduce the risk of exposure to Cryptosporidium and other organisms as well as improvements to water clarity and indoor air quality," Bokowy explained.

He went on to say that the "establishment of some industry standards is certainly a benefit in getting aquatic facilities to modernize. At the same time, the industry must do a better job of training operators and educating people at all levels of aquatic facility management [about] the risks associated with improper water treatment and the tools and techniques available to reduce those risks."

Ron George, aquatics division manager for a manufacturer of UV treatment systems, said water treatment today is about how facilities provide a cleaner, safer and more enjoyable experience for patrons, all while using less chemicals and wasting water.

"Water is the power of the future," George said. "We cannot exist without it. Technology is moving to solve all these issues at a reasonable cost while still reducing the risks to our patrons and the owner/operator.

"Systems today more closely monitor and control chemical use," he said. "Filtration today is utilizing technology to remove more organics from the water to provide a clearer, cleaner body of water to recreate or compete in. This is being accomplished with newer technology rather than conventional sand filtration. Regenerative media filtration filters more particles from the water using less water.

"The buzz phrase over the last few years, 'Recreational Waterborne Illness' (RWI), has led to a total re-evaluation of how we maintain aquatic facilities," he said. "Secondary and supplemental disinfection with validated ozone and ultraviolet light (UV) systems are now an integral part of any water treatment system today and in the future. The future of water treatment will see the use of less chemicals and new ways to treat the water."

As stated earlier, developments in water treatment include UV pool sanitizers being added, particularly at older indoor facilities and designed into newer facilities.

"That is a technology we hope would work. And, it is working," Griffiths said, adding that a technology also exists that has slower filtration rates. "The slower we filter the better off we are because it allows more time for the filter to catch the dirt."

The MAHC "qualifies UV and ozone as 'secondary sanitizers'," Arko added, "which may add an additional layer of safety to a facility. The addition of a filter enhancement clarifier to help remove pathogenic microbes quickly and efficiently is also highlighted."

Developments in water treatment include UV pool sanitizers being added, particularly at older indoor facilities and designed into newer facilities.

Other trends include standard filtration from particle removal and pathogen removal, as well as air quality.

"You get indoor facilities … and we've seen more and more illnesses associated with air quality, directly reflective of water quality," Sackett said. And, for sure, "a key item is huge bather load, but there's only so much you can do. We've got in the code, some of the combined chlorine disinfection byproducts and water quality issues ..."

"We've targeted some key areas of research associated with chloramines and ventilation," Sackett noted, adding that air quality and ventilation is becoming more of an issue for indoor facilities.

Fecal accidents in pools are another concern, particularly in how long it takes to deactivate the waste.

"That would be a good benefit to having secondary disinfection, a secondary treatment system working there for you all the time. The air quality, bather hygiene, instead of bringing in contaminants, decreases the contamination burden," he said.

But, pool patrons need to do their part, too.

To reduce the amount of contaminants in pools, experts suggest that people shower in cool water, without soap, before entering a public pool.

"We're trying to encourage mandating showers, acknowledging that instead of soapy hot showers, [to rinse off in cool water], but also recognizing that outdoor complexes [are] looking at rinse showers with immediate proximity to a pool," Sackett said.

From a hygiene standpoint at facilities, with diaper age children involved, you don't want diaper changing in and around the pool, either. If you have properly designed diaper changing stations, there should be no issues.

"They have to be properly designed and kept clean. Proper design is important," he said.

Similarly, Beach said there are increased risk venues, especially those that cater to young children. Secondary disinfection is important.

"We have to fix this. We need to start educating the public," Beach added. "A code can only do so much."

It's great to have rinse showers on the side, but the public needs to understand the issues as well.

"It's hard to enforce," Beach said.

But, the code strives to change that.

The idea is to take a classic public health sign that nobody probably looks at and incorporate key ideas on how facilities can use their ingenuity to get the word out about safety.

Lifeguard Training

Lifeguards are charged with the task of supervising the safety of swimmers at waterparks, swimming pools and beaches. But lifeguards need a break, too, something that Sackett said is addressed in the MAHC, stating that lifeguards shouldn't be in a position for more than 60 minutes at a time.

Proper rotation procedures are important, he said, adding that facilities need to always ensure that when a chair changing is taking place that someone is still watching the water. In addition, there should be a supervisor on staff who understands what the lifeguard is doing, the chair changes and that the lifeguards are adhering to the training they are taught.

However, it isn't always easy finding enough lifeguards.

"What we often hear from our partners that we work with in parks and recreation and what we've been hearing a lot of this past year is the difficulty in getting staff and maintaining staff through the summers," said Stephanie Shook, senior product manager, aquatics, Red Cross, Washington, D.C.

"It continues to be a struggle as people return to college or maybe just get burned out. There's a tendency to need staff at the end of summer," she said.

And, the health care laws have had an effect on the industry as well.

"Organizations are still making decisions based on whether they are going to pay benefits. So, that hit the industry, but lifeguards being part-time employees in seasonal fashion … those are not benefited positions," she added.

"We saw lifeguard training numbers go up a bit, a slight increase in Red Cross lifeguard training," she said.

In fact, the Red Cross recently completed the development of a new course that provides lifeguard training for shallow waters.

"Waterparks and recreation facilities have shallow depth waters. Some don't even get above two or three feet of water," Shook said. "Typically, swimming rescues don't apply to that."

But, the Red Cross in October announced its new professional lifeguard certification for extreme shallow water and the launch of two new programs that are designed to increase safety at facilities employing lifeguards.

The new Red Cross Aquatic Attraction Lifeguarding course trains lifeguards specifically who are guarding attractions in extreme shallow water, defined as three feet or less. This includes winding rivers, catch pools, slide runouts, water play areas and slide dispatch.

The need for a new designation was first identified by the Red Cross Aquatics staff in response to inquiries from waterpark customers. Extreme growth in shallow water attractions has translated to the need for lifeguards who are better trained in this area.

"Especially in waterparks, there are more and more attractions, not just play pool stuff anymore," Shook said. "This is more targeted toward that specific need."

The new certification follows two other lifeguard certifications, which are deep water lifeguarding and shallow water lifeguarding (up to five feet).

Specific to the Aquatic Attraction Lifeguarding course are adjustments to skills for water that is three feet or less, including a simple assist from any direction; handling passive victims who are either on the surface or submerged; and removal from the water on a backboard. First aid training places emphasis on caring for head, neck and spinal injuries that could be common in extreme shallow water accidents. The course also includes all of the content of the Red Cross Waterpark Skills module.

And, as with other Red Cross lifeguarding offerings, lifeguards must demonstrate full water competency to qualify to take the course. For Aquatic Attraction Lifeguarding, potential lifeguards must pass a water competency prerequisite sequence test as well as conduct brick retrieval at three feet. Lifeguards who complete the course successfully also will receive first aid, CPR and AED certification.

Shook explained that with the third certification program, actual water rescue is more targeted.

"The swimming rescues are not included because [the lifeguards] can stand up, and so we modified it … to be done by someone who is standing up," Shook said.

"We modified some rescues to be done without the rescue tube. That's what's different," she added. "Also, [we taught] additional ways to remove someone who is unconscious from the water."



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