Swimming is the third most popular U.S. sport or exercise activity, with approximately 314 million visits to recreational water venues, including treated venues (e.g., pools), each year (1). The most frequently reported type of recreational water illness (RWI) outbreak is gastroenteritis, the incidence of which is increasing (2). During 1997--2006, chlorine- and bromine-susceptible pathogens (e.g., Shigella and norovirus) caused 24 (23%) of 104 treated venue--associated RWI outbreaks of gastroenteritis, indicating lapses in proper operation of pools (2). Pool inspectors help minimize the risk for RWIs and injuries by enforcing regulations that govern public treated recreational water venues. To assess pool code compliance, CDC analyzed 2008 data from 121,020 routine pool inspections conducted by a convenience sample of 15 state and local agencies. Because pool codes and, therefore, inspection items differed across jurisdictions, reported denominators varied. Of 111,487 inspections, 13,532 (12.1%) resulted in immediate closure because of serious violations (e.g., lack of disinfectant in the water). Of 120,975 inspections, 12,917 (10.7%) identified disinfectant level violations. Although these results likely are not representative of all pools in the United States, they suggest the need for increased public health scrutiny and improved pool operation. The results also demonstrate that pool inspection data can be used as a potential source for surveillance to guide resource allocation and regulatory decision-making. Collecting pool inspection data in a standardized, electronic format can facilitate routine analysis to support efforts to reduce health and safety risks for swimmers.
Prevention of RWIs at treated venues requires pool operators to 1) maintain appropriate disinfectant and pH levels to maximize disinfectant effectiveness and 2) ensure optimal water circulation and filtration. Pool codes, promulgated by individual state or local public health agencies, govern pool operation.
CDC selected a convenience sample of 15 health agencies in four states and 11 counties or cities* to participate in an analysis of pool inspection data. For inclusion, data from inspections had to be in an electronic format and the agency had to provide ≥1,000 pool and spa inspection records† for 2008. Each agency's pool inspection data were standardized for analysis and included information on water chemistry, circulation and filtration system, policy and management, and pool setting and type. A violation was defined as an inspection item that did not meet standards set by the jurisdiction's pool code. CDC developed an algorithm based on facility name to classify pool setting (e.g., "hotel A" was coded as "hotel/motel"). Facility-identifying data then were deleted, and data from individual agencies were aggregated. Denominators in this report vary because pool codes, and therefore inspection items, differed across jurisdictions.
During 2008, inspectors in the 15 jurisdictions conducted a total of 121,020 routine pool inspections. Among the 121,020 inspections, the number of code violations identified ranged from 0 to 28 (median: 1), and 73,953 (61.1%) inspections identified one or more violations. A total of 13,532 (12.1%) of 111,487 inspections identified serious violations that threatened the public's health and resulted in immediate pool closure. Of 120,975 inspections, 12,917 (10.7%) identified disinfectant level violations; of 113,597 inspections, 10,148 (8.9%) identified pH level violations. Other water chemistry violations§ were documented during 12,328 (12.5%) of 98,907 inspections, with the number identified per inspection ranging from zero to four. Circulation and filtration violations¶ were documented during 35,327 (35.9%) of 98,361 inspections, with the number identified per inspection ranging from zero to nine. The following violations also were identified: improperly maintained pool log (12,656 [10.9%] of 115,874 inspections), unapproved water test kit used (2,995 [3.3%] of 90,088 inspections), valid pool license not provided and/or posted (741 [2.7%] of 28,007 inspections), and operator training documentation not provided and/or posted (1,542 [18.3%] of 8,439 inspections).
Of the 121,020 inspection records, 59,890 (49.5%) included pool setting data. Among venues with known pool settings, child-care pool inspections had the highest percentage of immediate closures (17.2%), followed by hotel/motel and apartment/condominium pool inspections (15.3% and 12.4% respectively) (Table 1). Apartment/condominium and hotel/motel pool inspections had the highest percentage of disinfectant level violations (13.1% and 12.8%, respectively). Child-care and apartment/condominium pool inspections had the highest percentage of pH level violations (11.8% and 10.0%, respectively). Approximately 35% of inspections of apartment/condominium pools, hotel/motel pools, and water parks identified circulation and filtration violations.
Of the 121,020 inspection records, 113,632 (93.9%) included pool type data. Interactive fountain inspections had the highest percentage of immediate closures (17.0%) (Table 2). Kiddie/wading pool inspections had the highest percentage of disinfectant level violations (13.5%), followed by interactive fountain inspections (12.6%). Therapy pool inspections had the lowest percentage of disinfectant and pH level violations but the highest percentage of other water chemistry violations (43.9%). Interactive fountain inspections identified the lowest percentage of circulation and filtration violations (12.8%).
L Hendrix, Jefferson County Dept of Health, Alabama. D Ludwig MPH, Maricopa County Environmental Svcs Dept, Arizona. B Franklin, Los Angeles County Environmental Health; C Maitoza, Sacramento County Environmental Management Dept, California. N Doxford, Florida Dept of Health. SE Ford, MD, DeKalb County Board of Health, Georgia. J Compton, Taney County Health Dept, Missouri. BF Buss, DVM, Career Epidemiology Field Officer Program, Office of Public Health Preparedness and Response, Nebraska Dept of Health and Human Svcs. D Sackett, New York State Dept of Health. D Salmen, Mecklenburg County Health Dept, North Carolina. K Krinn, MA, Columbus Public Health, Ohio. S Campbell, MES, Oklahoma City-County Health Dept, R Roth, Tulsa Health Dept, Oklahoma. E Florom, South Carolina Dept of Health and Environmental Control. T Clements, MS, King County Public Health, Washington. D Newell, Garrison Enterprises, Charlotte, North Carolina. EC Ailes, PhD, SA Collier, MPH, Atlanta Research and Education Foundation, Atlanta Veterans Admin Medical Center, Georgia. C Otto, Div of Emergency and Environmental Health Svcs, National Center for Environmental Health; JM Roberts, MA, Div of Parasitic Diseases, Center for Global Health; MC Hlavsa, MPH, MJ Beach, PhD, Div of Foodborne, Waterborne and Environmental Diseases (proposed), National Center for Zoonotic and Emerging Infectious Diseases (proposed); EL Dunbar, MPH, CDC/Assoc of Schools of Public Health Fellow, CDC.
This report is the second to examine pool code compliance in multiple U.S. jurisdictions. The first report analyzed aggregated pool inspection data collected during May 1--September 1, 2002, from six jurisdictions (3). This report examined data from more jurisdictions and for an entire year, resulting in a sample more than five times larger than reported previously. The conclusions from the two reports are similar: pool operation violations and immediate closures appear to be common in the United States. Although the sampled jurisdictions are not necessarily representative of the United States, the results underscore the public health importance of pool inspections. The results also underscore the potential for inspection data to better inform and direct public health decision-making regarding swimmer health and safety, particularly if these data are standardized.
Pool inspections are a key part of ensuring pool code compliance (4). This report indicates that routine pool inspections resulted in a high percentage (12.1%) of immediate closures because of serious code violations. Moreover, disinfectant and pH level violations were identified during 10.7% and 8.9% of pool inspections, respectively. Such violations are particularly important because improper disinfectant and pH levels can result in transmission of chlorine- and bromine-susceptible pathogens. Reduced chlorine levels and lower inspection scores have been associated with positive microbiologic water testing results (5). In this report, 18.3% of inspections noted that operator training documentation was not provided and/or posted as required. Pool operator training has been associated with decreased water quality violations (6).
This analysis suggests that efforts to prevent RWIs should focus on certain pool settings (i.e., apartment/condominium, hotel/motel, and child care) or types (i.e., kiddie/wading pools and interactive fountains). In pool settings where swimming is not the primary activity, the person responsible for pool operation likely has other competing responsibilities (e.g., heating and air conditioning maintenance). Requiring operator training for staff responsible for pool operation might improve water quality, and should be considered for these and other pool settings. Among pool types, maintaining adequate disinfectant levels at kiddie/wading pools and interactive fountains is challenging because shallow depth, aeration, sunlight, and organic material (e.g., feces, urine, sweat, and dirt) from young children deplete disinfectant. Disinfectant and pH levels should be measured and adjusted more frequently at these pool types, particularly when bather load is high.
The findings in this report are subject to at least three limitations. First, the results of these inspections might not be representative of inspections conducted by agencies nationwide. Second, some jurisdictions combined multiple inspection items into a single variable (to increase efficiency of data entry), which could lead to an underestimate of the actual total number of violations. Finally, pool setting was specified for <50% of inspections, limiting interpretation of these stratified results.
If pool inspection data were available in a standardized electronic format within a jurisdiction, routine analysis would be facilitated, which could better inform and direct public health decision-making at the state and local level, especially in an era of budget cuts and furloughs (7). For example, inspection programs might boost their effectiveness by targeting educational and regulatory enforcement activities at venues where inspection data indicate violations are disproportionately high. State and local agencies also could use inspection data for program evaluation (e.g., assessing closure and violation trends or differences in results by inspector), as demonstrated with other inspection data (8).
In 2005, federal, state, and local public health officials and aquatic sector representatives met to identify factors contributing to the increasing incidence of reported RWI outbreaks in the United States (2). They identified the variability of pool codes across jurisdictions as a key barrier to RWI prevention. Since 2007, CDC has sponsored a national, state, and local public health and aquatic sector effort to create a Model Aquatic Health Code (MAHC). MAHC will include national standards for pool design, construction, operation, and maintenance and guidance for inspections that are based on scientific evidence or best practices to reduce the risk for RWI and injury at public treated venues (9). Voluntary state and local adoption of MAHC could promote standardization of pool codes nationally and, in turn, could result in standardized pool inspection data by defining how and which elements are collected (Box). Standardized, electronic pool inspection data across jurisdictions would supply needed baseline data and enable future monitoring and evaluation of MAHC as a public health resource for state and local jurisdictions in their efforts to promote swimmer health and safety.
This report is based, in part, on contributions by E Wright, Jefferson County Dept of Health, Alabama; G Epperson, Maricopa County Environmental Svcs Dept, Arizona; M Davin, Pueblo City-County Health Dept, S Evans, Weld County Dept of Public Health and Environment, Colorado; R Vincent, P Anderson, Florida Dept of Health; B Trundle, Catoosa County Environmental Health, R Cira, MPH, S Gaines, DeKalb County Board of Health, D Hornsby, L Westcott, Gwinnett County Environmental Health, Georgia; M Mettler, Environmental Public Health Div, K Harrington, R Hooton, St. Joseph County Health Dept, Indiana; L Linnenbrink, Scott County Health Dept, Iowa; G Edwards, A Georgeson, Minnesota Dept of Health; C Fernandez, Environmental Health Dept, City of Minneapolis, Minnesota; L Hunter, L Randolph, Taney County Health Dept, Missouri; T Huffman, J Daniel, Nebraska Dept of Health and Human Svcs; T Wilson, New Hampshire Dept of Environmental Svcs; D Mead, T Shay, New York State Dept of Health; C Stilwell, Mecklenburg County Health Dept, North Carolina; K Madden, Columbus Public Health, Ohio; M Rockey, C Li, Oklahoma City-County Health Dept, Oklahoma; SB Keifer, E Van Ess, Oregon Dept of Human Svcs; J Kawaguchi, Multnomah County Environmental Health, Oregon; D Cinpinski, Allegheny County Health Dept, Pennsylvania; JL Ridge, South Carolina Dept of Health and Environmental Control; T Vyles, MA, Plano Health Dept, G Rothbarth, W Turpen, Tarrant County Public Health, Texas; RM Mason, L Wood, Tennessee Div of General Environmental Health; S Hughes, Alexandria Dept of Health, C Gordon, Virginia Dept of Health; M McGinn, Clark County Environmental Public Health, S Main, Spokane County Health Dept, B Petek, Kitsap County Health District, D DeLong, Tacoma-Pierce County, G Fraser, Office of Environmental Health, Safety, and Toxicology, Washington; N Bloomenrader, Wyoming Dept of Agriculture; and C Nolan, Garrison Enterprises, Charlotte, North Carolina.
US Census Bureau. Recreation and leisure activities: participation in selected sports activities 2007. Available at http://www.census.gov/compendia/statab/2010/tables/10s1212.pdf. Accessed May 17, 2010.
CDC. Surveillance for waterborne disease and outbreaks associated with recreational water use and other aquatic facility-associated health events---United States, 2005--2006. MMWR 2008;57(No. SS-9):1--33.
CDC. Surveillance data from swimming pool inspections---selected states and counties, United States, May--September, 2002. MMWR 2003;52:513--6.
van Weerdenburg K, Mitchell R, Wallner F. Backyard swimming pool safety inspections: a comparison of management approaches and compliance levels in three local government areas in NSW. Health Promot J Austr 2006;17:37--42.
Hadjichristodoulou C, Mouchtouri V, Vousoureli A, et al. Waterborne disease prevention: evaluation of inspection scoring system for water sites according to water microbiological tests during the Athens 2004 pre-Olympic and Olympic period. J Epidemiol Community Health 2006;60:829--35.
Buss BF, Safranek TJ, Magri JM, Török TJ, Beach MJ, Foley BP. Association between swimming pool operator certification and reduced pool chemistry violations---Nebraska, 2005--2006. J Environ Health 2009;71:36--40.
National Association of County and City Health Officials. LDH budget cuts and job losses: 2010 data confirm job losses and program cuts in LHDs continue. Washington, DC: National Association of County and City Health Officials; 2010. Available at http://www.naccho.org/advocacy/lhdbudget.cfm. Accessed May 17, 2010.
Cramer EH, Blanton CJ, Otto CM. Shipshape: sanitation inspections on cruise ships, 1990--2005, Vessel Sanitation Program, Centers for Disease Control and Prevention. J Environ Health 2008;70:15--21.
CDC. Model Aquatic Health Code. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available at http://www.cdc.gov/healthywater/swimming/pools/mahc. Accessed May 10, 2010.
* The 15 participating agencies and their total number of routine pool inspections conducted in 2008: Florida Department of Health (52,752), Nebraska Department of Health and Human Services (1,132), New York State Department of Health (7,384), South Carolina Department of Health and Environmental Control (22,111), Columbus (Ohio) Public Health (2,117), DeKalb County (Georgia) Board of Health (2,755), Jefferson County (Alabama) Department of Health (982), King County (Washington) Public Health (2,300), Los Angeles County (California) Environmental Health (7,890), Maricopa County (Arizona) Environmental Services Department (15,075), Mecklenburg County (North Carolina) Health Department (1,248), Oklahoma City-County (Oklahoma) Health Department (1,802), Sacramento County (California) Environmental Management Department (1,016), Taney County (Missouri) Health Department (549), Tulsa (Oklahoma) Health Department (1,907).
† Although data from the agencies included hot tub inspection records, this report focused only on pool inspection data.
§ Aggregated, dichotomous variable indicating whether at least one of the following inspection items was found to be in violation: cyanurate levels, algae, bacterial quality, disinfectant/pH chemical feeders, total alkalinity, calcium hardness, total dissolved solids, saturation index, and oxidation reduction potential.
¶ Aggregated, dichotomous variable indicating whether at least one of the following inspection items was found to be in violation: turbidity, cross connections, flow meter, water level, turnover, skimmer/gutter, weirs, filter, gauges, and pipe labeling.
Pool inspection programs are important in assessing and enforcing compliance with pool codes aimed at minimizing the risk for recreational water illness and injury.
Analysis of routine pool inspection data from a convenience sample of 15 jurisdictions with 121,020 inspections found that almost one out of eight inspections conducted in 2008 resulted in immediate closure because of serious code violations (e.g., lack of disinfectant in the water).
Pool inspection data can be used as a potential source for surveillance to guide resource allocation and regulatory decision-making to reduce health and safety risks for swimmers; the Model Aquatic Health Code can facilitate systematic collection of pool inspection data.
* Florida, Nebraska, New York, South Carolina, Columbus (Ohio), DeKalb County (Georgia), Jefferson County (Alabama), King County (Washington), Los Angeles County (California), Maricopa County (Arizona), Mecklenburg County (North Carolina), Oklahoma City-County (Oklahoma), Sacramento County (California), Taney County (Missouri), and Tulsa (Oklahoma).
† Apartment/condominium inspections (n = 34,504) include venue titles containing: apartment, apt, condo, home owners association, property owners association, residents association, townhome, and townhouse.
§ Campground inspections (n = 466) include venue titles containing: campground, camping, campsite, and campground chain names.
¶ Camp inspections (n = 706) include venue titles containing: camp, day camp, overnight camp, summer program, and summer camp.
** Child care inspections (n = 92) include venue titles containing: daycare, preschool, and nursery school.
†† Hospital inspections (n = 207) include venue titles containing: hospital, medical, physical therapy, and rehabilitation.
§§ Hotel/motel inspections (n = 16,569) include venue titles containing: motel, hotel, resort, and hotel and motel chain names.
¶¶ Membership club inspections (n = 4,405) include venue titles containing: athletic club, fitness, gym, sports club, country club, and certain national clubs and health associations.
*** Municipal inspections (n = 1,020) include venue titles containing: city of, city pool, county, municipal, parks and recreation, public bath, public pool, town of, and civic association.
††† School/university inspections (n = 1,578) include venue titles containing: public school, college, university of, univ., and elementary, middle, and high schools.
§§§ Water park inspections (n = 343) include venue titles containing: adventure, amusement park, water park, and waterslide.
¶¶¶ Unknown inspections (n = 61,130) include venues where setting algorithim could not identify setting based on facility name.
**** Aggregated, dichotomous variable indicating whether at least one of the following inspection items was found to be in violation: cyanurate levels, algae, bacterial quality, disinfectant/pH chemical feeders, total alkalinity, calcium hardness, total dissolved solids, saturation index, and oxidation reduction potential.
†††† Aggregated, dichotomous variable indicating whether at least one of the following inspection items was found to be in violation: turbidity, cross connections, flow meter, water level, turnover, skimmer/gutter, weirs, filter, gauges, and pipe labeling.
§§§§ Not applicable; no violations found.
† Interactive fountain inspections (n = 95) include splash parks, spray pads, and wet decks.
§ Kiddie/wading inspections (n = 5,900).
¶ Other pool type inspections (n = 2,043) include special purpose pools, water attractions, water activity, water slides, and lazy rivers.
** Pool inspections (n = 105,495) include traditional swimming pools and exclude interactive fountains, kiddie/wading pools, other pool types, or therapy pools.
†† Therapy inspections (n = 99) include therapy pools.
§§ Unknown inspections (n = 7,388) include pools where type was not recorded at inspection.
¶¶ Aggregated, dichotomous variable indicating whether at least one of the following inspection items was found to be in violation: cyanurate levels, algae, bacterial quality, disinfectant/pH chemical feeders, total alkalinity, calcium hardness, total dissolved solids, saturation index, and oxidation reduction potential.
*** Aggregated, dichotomous variable indicating whether at least one of the following inspection items was found to be in violation: turbidity, cross connections, flow meter, water level, turnover, skimmer/gutter, weirs, filter, gauges, and pipe labeling.
††† Not applicable; no violations found.
Provide a unique identifier for each venue (e.g., permit number or facility title).
Generates a violation history for each venue.
Provide a unique identifier for each body of treated recreational water at a venue.
Generates a violation history for each body of treated recreational water at the venue. This allows tracking of specific high-risk areas at larger venues (e.g., kiddie pools).
Provide a unique identifier for each inspection of each individual body of treated recreational water at an aquatic venue (i.e., do not include multiple bodies in one inspection record).
Allows analysis of inspection data by body of treated water over time.
Specify pool setting (e.g., hotel/motel or apartment/condominium).
Allows identification of differences in risk for recreational water illnesses and injuries by pool setting.
Specify pool type (e.g., pool, wading pool, therapy pool, or interactive fountain).
Allows identification of differences in risk for recreational water illnesses and injuries by pool type.
Specify water location (i.e., indoor or outdoor).
Allows identification of differences in maintaining water and air quality by location.
Specify type of inspection conducted (e.g., routine inspection or inspection in response to public complaint).
Directs program planning and evaluation and provides census of mandatory inspections.
Identify inspector who conducted inspection.
Allows identification of differences among inspectors and helps ensure uniformity of program inspections.
Limit each data field to one inspection item (e.g., do not combine multiple violations into one field).
Facilitates data interpretation and analysis.
Set value limits for data entry for each inspection item.
Reduces data entry errors and facilitates data analysis.
Differentiate among inspected items found to be in compliance, out of compliance, corrected on the spot, not observed, or not applicable.
Allows determination of the number of inspections in the denominator of the proportion of inspections with identified violations. Proportions can be used to track trends over time.
Standardize inspector notes (e.g., provide a pick list).
Facilitates data entry and analysis. Inspector's notes (e.g., "pH is too low and needs to be raised") provide detailed information.
Differentiates among disinfectants, which have different required minimum and/or maximum levels.
Allows analysis of critical variables, particularly those with upper and lower limits, to determine which limits were violated. Total and free disinfectant levels can be used to calculate combined disinfectant levels.
If data entry is too resource intensive, prioritize by order of importance (e.g., inspection items that if found to be in violation would result in closure).
Facilitates data entry and analysis.
Specify inspection outcome (e.g., pool closed due to serious violations, pool passed inspection, or reinspection needed).
Directs program planning and evaluation.
Log time required for inspection.
Assesses resource requirements and guides resource allocation.
Design database that is flexible and allows data fields to change over time.