The Model Aquatic Health Code (MAHC)What it is and How it was Developed

International Health Regulators Forum for Establishments that

Handle Contact Water

June 6th-9th, 2017 Douglas Sackett

Executive Director, CMAHC

AGENDA

What is the MAHC?

Reasons for the MAHC

MAHC Development

Keeping the MAHC up-to-date

MAHC Adoption/Implementation

MAHC Outcomes

What is the MAHC?

Voluntary model public pool and spa code based on science and best practices created by the Centers for Disease Control & Prevention (CDC) 1st Edition released August 2014

2nd Edition released July 2016

Helps local and state authorities and aquatics sector make swimming and other water activities healthier and safer

States and localities can use the MAHC to create or update existing pool codes To reduce risk for outbreaks, drowning, and pool-chemical injuries

All-inclusive and addresses design, construction, operation, maintenance, policies, and management of public aquatic facilities.

MAHC Scope

All areas of public health concern

Illness, injury, drowning

Public venues

Water, air, & facility exposures that impact the health of swimmers and facility users

Leave other areas to building codes, etc.

Facility types

Man-made, treated, recirculated water venues

Health care-based pools

Therapy pools

MAHC Building Blocks

Data or best practices driven Avoid prescription when possible

Free and accessible for all Posted on CDC’s Healthy Swimming website

Implementable Incremental change: “Evolution, not revolution"

Updated regularly Current update cycle is every 2 years

Easy to understand Code section accompanied by “Annex” that includes

data and rationale for code requirements

MAHC Core Work Strategies

The core work strategies used for MAHC development included:

Use an “Evolution NOT Revolution” approach

Build a strong partnership between public health and the aquatics sector

Actively seek, listen to, and incorporate public input

Rationale

Incremental change is most likely to be adopted by state and local jurisdictions

Partnership will yield the best product, greatest buy-in, and will be most likely to be adopted

Incorporating public input improves overall quality and national buy-in

Why the MAHC?Support the Health Benefits of Swimming

One of top sports in the US – >300 million visits a year

Low impact exercise improves joint use with arthritis and cardiovascular health

Improves mood

Improves quality of life and reduces disability

Maintains bone health for post-menopausal women

For more information, see http://www.cdc.gov/healthywater/swimming/health_benefits_water_exercise.html:

Public Health Issues Detracting from Aquatics Benefits

Drowning 2nd leading cause of unintentional death from injury for ages 1-14 with ~3500/people/yr1

Spinal cord injuries; ~10,000 /year with ~4.5% (1995-2000) from diving (~450/yr)2

Indoor air quality issues due to di- and tri-chloramine and DBP production3

Pool chemical-associated injuries caused ~5000 people ED visits in 20124

Operational issues closed 12.1% of pools during routine inspections5

1 CDC. MMWR 2012;61:344-347; 2 DeVivo, 2003; 3 Weisel et al. Environ Hlth Perspect. 2009;117:500-507; 4 Hlavsa et al. MMWR 2014;63:427-430; CDC. MMWR 2010;59:582–7.

Current Pool Regulation Situation

Highest use, highest number of outbreaks

Little federal regulation, no federal jurisdiction

Disparate, variable regulation at state, local level

Little funding for public health research

What can be done to improve growing problem?

MAHC GENESIS AND BEGINNINGS

MAHC Genesis

CDC-sponsored workshop, 2005

“Recreational Water Illness Prevention at Disinfected Swimming Venues”; Atlanta, Georgia

Recommendation #1

Create model standards with broad input

Include disease, injuries, & drowning prevention

Make it data-driven, knowledge-based

Write for local and state health jurisdictions

Update regularly based on new data

Give open access to all users

MAHC Organization and Process

May 2007: NCEZID/NCEH organized Steering Committee

Federal/state/local PH, industry, academia included

Doug Sackett, NYS asked to be Director

Develop organizational plan, structure, and examples

Fall 2008: Organize Technical Committees

Appoint Chairs, recruit membership

Spring 2009: Initial Technical Committees start work

CDC clearance, public comment process (OGC-approved) Clear modules, posts on website for 60-day public comment

Revise modules based on comment and repost

Revised modules merged into single document and reposted for 2nd and final public comment

MAHC Process

Steering Committee

(Director, 9 members)

Coordinator, Assistant to Director,

& Technical Writer

Public

Comment X 2

New or Revised MAHC

12 Technical Committees

MAHC Steering Committee

Director: Douglas Sackett, New York State Dept. of Health

Michael Beach, Centers for Disease Control & Prevention

Chip Cleary, International Association of Amusement Parks and Attractions

Tracynda Davis, National Swimming Pool Foundation, representing NEHA

Jim Dunn, Aquatic Development Group

John Linn, SeaWorld Parks & Entertainment

Colleen Maitoza, County of Sacramento Environmental Management Department

Chuck Neuman, Water Technology, Inc.

Charles Otto, Centers for Disease Control & Prevention

Bob Vincent, Florida Dept. of Health

MAHC Technical Committees

Contamination Burden Chairperson: Ellen Meyer

Disinfection & Water Quality Chairperson: Jim Dingman

Facility Design & Construction Chairperson: Carl Nylander

Facility Maintenance & Operation Chairperson: Michael Beatty

Hygiene Facilities Chairperson: Ralph Cordell

Lifeguarding/Bather Supervision Chairperson: M. Kathryn Scott

Monitoring & Testing Chairperson: Vincent Hill

Operator Training Chairperson: Dennis Berkshire

Recirculation Systems & Filtration Chairperson: James Amburgey

Regulatory Program Administration Chairperson: Frank Guido

Risk Management/Safety Chairperson: Amy Duck

Ventilation & Air Quality Chairperson: Franceen

Gonzales

MAHC Development: Process and Timeline

14 Modules

Develop modules; Post for 1st round of

public comment10/2010-7/2013

Merge all modules;Post “Knitted” Version for 2nd

(final) round of public comment

3/20141428 comments

Revise-repost all modules.

2979 comments: 76% of comments asking for change accepted

14 Modules

Revised & postedMAHC 1st Edition

4,407 comments addressed with 72%

accepted

CompletedCompleted Completed August 29, 2014

MAHC: Key Points to Keep in Mind

Numerous opportunities for input and public comment >150 people from across PH, aquatics, academia

created modules Two rounds of public comment with over 4400

comments and >70% acceptance rate 3rd round of input if state/local adopting MAHC

Major design and construction elements primarily pertain to “new” or substantially altered construction” – not retrofitting except where specified

MAHCCODE LANGUAGE & ANNEX

What’s Inside?

1) Preface

2) User Guide

3) Glossary, Acronyms, Initialisms

4) Design and Construction

5) Operation and Maintenance

6) Policies and Management

7) MAHC Resources

8) Appendices

MAHC RENEWAL:KEEPING THE MAHC UP-TO-DATE

The Conference for the Model Aquatic Health Code (CMAHC)

What is CMAHC ?

501c(3) non-profit organization

Why does it exist ?

Established in 2013 to manage updates to the MAHC

Administration & Operation

Bylaws, Board of Directors, Executive Director

Committees include Technical Review Committee and Ad Hoc Committees

The Conference for the Model Aquatic Health Code (CMAHC)

Role

Conduit for funneling advice and data-driven, science-based information from public health and aquatic industry experts to CDC

Support use of MAHC

Vision

To keep the MAHC up-to-date, science-based, sustainable, easily understood and implemented by pool programs across the U.S. so as to support healthy and safe aquatic experiences for everyone.

The Conference for the Model Aquatic Health Code (CMAHC)

Mission

Collect, assess, and relay input on MAHC revisions back to CDC for final acceptance

Provide advocacy and needed support to health departments and other partners on using the MAHC

Solicit, coordinate, and prioritize research needs

CMAHC Biennial Conference

CMAHC Biennial Conference will be hosted every two years

Biennial CMAHC meetings: 2015, 2017, 2019, 2021, 2023, 2025, 2027, 2029

New MAHC Edition launches at CDC: 2016, 2018, 2020, 2022, 2024, 2026, 2028, 2030

CMAHC Working Structure: General Outline

InputChange Request

Technical Review & Discussion

CDC

Conference & Voting

Board of Directors

Standing Committees

DISINFECTION BY-PRODUCTS

MAHC ADOPTION

MAHC Features to Encourage Implementation

Voluntary science-based standards

Modular format allowing flexibility for jurisdictional needs

Design elements apply to new construction only

“Evolution, not revolution”

Diverse stakeholder involvement Public health partners

Coordination between building code officials and public health practitioners

User Guide under development

MAHC Adoption Status

Key considerations States must review and fit into regulatory process and timeframe:

adoption can take > 2 years; Food Code sped up after 3-6 years

Endorsements NACCHO 2015; NEHA imminent; CSTE 2017?

Adoption Full adoption: NM (08/01/2016 after 2+ years prep); Nova Scotia,

Canada

Partial adoption: DE, PWTAG/UK

In review for potential adoption: almost 30 jurisdictions such as CO; IA; IN; MD; NY; OH; Ontario, Canada; Colombia

Clear role for aquatics sector advocacy to speed adoption

Visible Groundswell Following MAHC Release: Becoming a Standard While Waiting for Adoption

Operational adoption: Use in operations, MAHC-compliant operational materials, and operational assistance

e.g., YMCA operations manual, Great Wolf Lodge operational guidance, Jeff Ellis & Assoc. guarding materials

Variances granted: MAHC-based variances/waivers given liberally to requestors while discussing adoption (e.g., FL, NY, CT)

Surrogate pool code: States without a pool code pointing to MAHC for design, operation, management guidance (e.g., MS)

Acceptance of design requirements: MAHC design features becoming accepted and not immediately removed from designs due to cost

Clients signing liability waivers if they require removal (e.g., UV disinfection on increased risk venues)

Standard of care: Being referred to as standard of care based on expert witness feedback

ANTICIPATED OUTCOMES

Short Term Outcomes: Immediate After Guidelines Adopted

Automated controllers and feeders

Chemical feeder-recirculation interlocks

Diaper changing station criteria

Training for pool operators

Performance-based lifeguarding

Preventive maintenance checks

Policies: employee illness, body fluid response, pool surface cleaning to reduce biofilm

MAHC Outcomes: Intermediate Term

Improved operations

Adoption of minimum standards across the U.S. (as with national food safety and building model codes)

Systems-based approach to facility design, operation, maintenance, policy

Reductions in pool closures due to imminent threats

Improved pool programs

Improved surveillance systems

Improved data collection

Data-based decision making

MAHC Outcomes: Long Term

Extensive research agenda

Prioritize data needed to drive MAHC changes

Drive fund raising efforts

Long-term outcome

Reductions in RWIs, injuries, drowning

CONCLUSIONS & FUTURE DIRECTIONS

MAHC and Pool Program Benefits

Saves state/local resources being used to essentially “reinvent the wheel” in separate jurisdictions

Scientifically or best practices based guidance

Renewed on biennial basis like model food code

Creation of toolkit with forms/guides to assist facilities

Will include “administrative code” guidance for pool programs with forms/guidance

Was initially in MAHC but is now separated because “can’t regulate the regulators” concerns

MAHC and Pool Program Benefits

Assist programs in more efficiently collecting data and analyzing it for use in decision making,

Assist with building uniformity across jurisdictions

Build relationships with building code inspectors

Build stronger relationships with aquatics industry since they have been involved from the beginning

Could be beneficial during state adoption

MAHCMore Information: Search on

“CDC MAHC” or visit the Healthy Swimming MAHC

Website: www.cdc.gov/mahcEmail: mahc@cdc.gov

CMAHCMore Information: Search on “CMAHC” or visit the CMAHC

Website: www.cmahc.orgEmail: info@cmahc.org

Contact Information

Doug Sackett

Executive Director, CMAHC

E-mail: DouglasSackett@cmahc.org

Phone: 678-221-7218

QUESTIONS ?