Rationale Behind the MAHC

Over 300 million visits to aquatic venues occur each year making swimming the fourth most popular recreational activity in the United States and the most popular recreational activity for children and teens ¹. However, over the past several decades, public aquatic venues have been associated with significant increases in disease outbreaks and the continued occurrence of drowning and injuries. These health and safety issues include:

• Drowning. Drowning is one of the top causes of unintentional injury death for children older than 1 year ^3-4. Non-fatal drowning can cause brain damage resulting in learning disabilities or even permanent loss of basic functioning ^5,6.
• Injuries and emergency department (ED) visits. Injuries linked to pool chemicals accounted for almost 3,000-5,000 emergency department visits per year (2003-2012) ^8-12. Almost half of the patients were aged <18 years ^8-12.
• Waterborne illness outbreaks. The number of illness outbreaks associated with recreational water has increased significantly since CDC began collecting these data in 1978 from an average of 15 per year (1993-2002) to 34 per year (2003-2012) ². Most of the increase is due to outbreaks caused by the chlorine-tolerant parasite Cryptosporidium ^13-14. A single outbreak can sicken thousands ¹⁵.
• Public pool and hot tub closings because of public health hazards. A recent study found that 11.8% (about 1 out of 8) inspections of public pools and 15.1% (about 1 out of 7) of inspections of public hot tubs/spas resulted in immediate closure because of serious health or safety hazards ¹⁶. Other pool inspection data analyses show similar results ^17-18.
• Evidence of pool water contamination. Sampling of public pool filters shows evidence of contamination (59% [95/161] of samples Pseudomonas aeruginosa positive) and from feces (58% [93/161] of samples E. coli positive) ¹⁹. In another U.S. study of pool filters, 8.1% (13/161) of samples were positive for Cryptosporidium, Giardia, or both ²⁰.

In the United States, there is no federal regulatory authority responsible for public disinfected aquatic facilities like pools, waterparks, and spas as there is for natural waters (lakes, rivers) through the US Environmental Protection Agency ²¹. As a result, the health and safety at public disinfected aquatic facilities is regulated by state and local jurisdictions: 68% of local health departments have public pool inspection programs ²². All public pool codes are developed, reviewed, and approved by state and/or local public health officials or legislatures. Consequently, there is no uniform national guidance informing the design, construction, operation, and maintenance of public swimming pools and other disinfected aquatic facilities. As a result, the code requirements for preventing and responding to recreational water illnesses (RWIs), drowning, and injuries can vary significantly among local and state agencies. State and local jurisdictions spend a great deal of time, personnel, and resources creating and updating their individual codes on a periodic basis.

The Model Aquatic Health Code’s (MAHC) vision is "Healthy and Safe Aquatic Experiences for Everyone." The MAHC’s mission is to provide guidance on how state and local officials can transform a typical health department pool program into a data-driven, knowledge-based, risk reduction effort to prevent disease and injuries and promote healthy recreational water experiences. The MAHC provides local and state agencies with uniform guidelines and wording covering design and construction, operation and maintenance, and policies and management of swimming pools and other public disinfected aquatic facilities. The availability of the MAHC provides state and local agencies with the best available guidance for protecting public health so they can use it to create or update their swimming pool codes while conserving valuable time and resources previously used to write or update code language. The guidance will be regularly updated using input from a national stakeholder partnership called the Council for the Model Aquatic Health Code (CMAHC) to keep the MAHC up to date and current with the latest advances in the aquatics industry while also responding to public health reports of disease and injury.

Short-term Outcomes: Use of the MAHC should help reduce the risk of diseases and injuries and promote healthy and safe swimming. We anticipate that the practices promoted in the MAHC will initially lead to the following system improvements:

• Fewer pool and facility closures
• More-meaningful inspection and tracking/surveillance data
• An established research agenda to drive future iterations of the MAHC
• Enhanced collaboration among stakeholders

Long-term Outcomes: By adopting the practices outlined in the MAHC, jurisdictions should also be able to improve the long-term health and safety of aquatic facilities. This should include a reduced risk of the following:

• Outbreaks of waterborne illnesses
• Drowning incidents
• Injuries from pool chemicals and disinfection by-products
• Swimming-related emergency department visits

CDC is developing systems to track the impact and potential health improvements related to this national public health effort.