Association between swimming pool operator certification and reduced pool chemistry violations Nebraska, 2005-2006

Journal of Environmental Health, April, 2009 by Bryan F. Buss, Thomas J. Safranek, Julie M. Magri, Thomas J. Torok, Michael J. Beach, Brett P. Foley

Introduction

Swimming is the most popular children's recreational activity in the United States and the second most popular exercise activity for all ages, with more than 360 million visits to recreational water venues each year (Bureau of the Census, 1995). This popularity is paralleled by growing numbers of reported outbreaks of illness associated with recreational water exposure (Dzuiban et al., 2006). In December 2006, a waterborne disease outbreak occurred as a result of chloramine toxicity in an indoor motel swimming pool in Nebraska (Centers for Disease Control and Prevention [CDC], 2007). Mismanagement of this pool by an uncertified operator with no verifiable training caused the toxicity, which affected 24 persons who experienced ocular and respiratory illness. In this preventable outbreak, five persons required medical attention, including a six-year-old boy who was hospitalized in a pediatric intensive care unit for severe chemical epiglottitis and laryngotracheobronchitis. In response, this pool was inspected by Nebraska Department of Health and Human Services (NDHHS) and closed because of chemical abnormalities that resulted in multiple violations.

Since 1978, the Centers for Disease Control and Prevention (CDC), U.S. Environmental Protection Agency (U.S. EPA), and the Council of State and Territorial Epidemiologists (CSTE) have maintained a collaborative surveillance program for collection and periodic reporting of data on the occurrence and causes of waterborne disease outbreaks associated with recreational water in the United States. In response to the outbreaks detected by this surveillance program, CDC Morbidity and Mortality Weekly Report Surveillance Summaries have offered recurrent recommendations citing the need to maintain adequate pool water chemistry, improve procedures to operate and maintain public pools, and enhance training of public pool operators and staff (Dzuiban et al., 2006; Lee, Levy, Craun, Beach, & Calderon, 2002; Levy, Bens, Craun, Calderon, & Herwaldt, 1998; Moore et al., 1993; Yoder et al., 2004). Throughout the United States, swimming pool operators are responsible for correct maintenance and operation of public pools; however, minimal public health oversight exists (CDC, 2003). As a result, water-borne disease outbreaks are often the direct result of mismanagement of public swimming pools. This indicates a need for standard mandatory education for all public pool operators (Bowen et al., 2007; CDC, 2003; Dzuiban et al., 2006). Despite the probability that mandatory training will prevent recreational water illness, data to substantiate this recommendation are limited.

In response to the December 2006 preventable outbreak of chloramine-associated illness resulting from the Nebraska motel swimming pool (CDC, 2007) and the lack of data to support national recommendations for standard mandatory education for all public pool operators or to demonstrate the benefits, the NDHHS Office of Epidemiology initiated a cross-sectional study of statewide pool inspection data. The objective was to evaluate the association between swimming pool operator certification and training requirements, and water chemistry violations, which are indicators of mismanagement of Nebraska pools.

Methods

For this cross-sectional study of Nebraska statewide pool inspection reports during January 2005-December 2006, the association between pool operator certification and chemistry violations of state regulations was evaluated. Nebraska requires a minimum of one annual inspection per pool (Nebraska Department of Health and Human Services, 2004). Analysis was limited to routine inspection reports containing values for both free chlorine and pH. Unacceptable values for either were used as indicators of mismanagement by pool operators because they constitute serious violations and are grounds for immediate pool closure. Start-up, follow-up, and complaint inspections were excluded. Public swimming pools in Nebraska are designated as either Class A or Class B. Class A includes all municipal public swimming pools. State regulations require these pools in all Nebraska counties to have trained certified operators on site at all times when open. Class B includes nonmunicipal pools operated by motels, hotels, apartment complexes, condominiums, child care facilities, property owner associations, and health clubs. In contrast to the statewide operator certification requirements for Class A pools, only Douglas County and the city of Lincoln in Lancaster County have local ordinances that require trained and certified operators for nonmunicipal, Class B pools. In all other Nebraska counties (n = 91), state regulations do not require operator certification for Class B pools.

By using only inspections from counties without Class B operator certification requirements, Class B free chlorine violations (free chlorine < 2 ppm or free chlorine > 10 ppm) were first compared with those of Class A pools. Then statewide Class B inspections were evaluated by comparing free chlorine violations in Douglas County and Lincoln nonmunicipal pools with those in all other counties that do not have operator certification requirements.