Despite the development of the Model Aquatic Health Code (MAHC), U.S. public health departments and aquatics agencies face obstacles in incorporating this guidance into their pool codes. A cross comparison of five state pool codes with the MAHC was conducted to quantify MAHC incorporation into these state codes. The proportion of MAHC code agreement with state codes in this study had a range of 14%–86%. Only 2% of all the MAHC codes available were present in all five state codes, conversely, 12% of the MAHC codes were not found in any state. These differences in code agreement highlight the challenge of measuring MAHC effectiveness at the national level. To improve aquatic safety at a national level, a potential solution is development and use of common core elements in state and local pool codes. Once there is a basis for code comparisons across states, public health programs can investigate whether core MAHC codes result in reduced waterborne illness outbreaks, drowning incidents, injuries from pool chemicals, health outcomes from exposure to disinfection by-products, and swimming-related emergency department visits. This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

The article reports on the submission of a change request proposing the inclusion of text specific to surf venues for the 4th edition of the 2023 U.S. Centers for Disease Control and Prevention (CDC) Model Aquatic Health Code (MAHC), a guidance to help prevent public aquatic venue-associated illness and injury. Topics covered include discussion topics that have included revising, how artificial swimming lagoons (ASL) are being addressed, and the challenges of developing guidance for ASL.

In June 2021, Kansas state and county public health officials identified and investigated three cases of shigellosis (a bacterial diarrheal illness caused by Shigella spp.) associated with visiting a wildlife park. The park has animal exhibits and a splash pad. Two affected persons visited animal exhibits, and all three entered the splash pad. Nonhuman primates are the only known animal reservoir of Shigella. The splash pad, which sprays water on users and is designed so that water does not collect in the user area, was closed on June 19. The state and county public health codes do not include regulations for splash pads. Thus, these venues are not typically inspected, and environmental health expertise is limited. A case-control study identified two distinct outbreaks associated with the park (a shigellosis outbreak involving 21 cases and a subsequent norovirus infection outbreak involving six cases). Shigella and norovirus can be transmitted by contaminated water; in both outbreaks, illness was associated with getting splash pad water in the mouth (multiply imputed adjusted odds ratio [aOR(MI)] = 6.4, p = 0.036; and 28.6, p = 0.006, respectively). Maintaining adequate water disinfection and environmental health expertise and targeting prevention efforts to caregivers of splash pad users help prevent splash pad-associated outbreaks. Outbreak incidence might be further reduced when U.S. jurisdicitons voluntarily adopt CDC's Model Aquatic Health Code (MAHC) recommendations and through the prevention messages: "Don't get in the water if sick with diarrhea," "Don't stand or sit above the jets," and "Don't swallow the water."(†).

The article discusses the launch of the Model Aquatic Health Code (MAHC) by the U.S. Centers for Disease Control and Prevention to enhance the safety and health of aquatic venues. Topics mentioned include the inclusion of guidelines and best practices about the prevention of pathogen transmission, illness and injury in the code, the MACH definition of splash pad and wading pool, and other web sites that can help prevent transmission of pathogens in public pools and water playgrounds.

On September 6 and 20, 2017, Hurricanes Irma and Maria made landfall as major hurricanes in the US Caribbean Territories of the Virgin Islands and Puerto Rico with devastating effects. As part of the initial response, a public health team (PHT) was initially deployed as part of the US Department of Health and Human Services Incident Response Coordination Team. As a result of increased demands for additional expertise and resources, a public health branch (PHB) was established for coordinating a broad spectrum of public health response activities in support of the affected territories. This paper describes the conceptual framework for organizing these activities; summarizes some key public health activities and roles; outlines partner support and coordination with key agencies; and defines best practices and areas for improvement in disaster future operations. © 2021 Weston Medical Publishing. All rights reserved.

Aquatic activities play an important role for many when it comes to living a healthy lifestyle. Not only is swimming great exercise, it can help to maintain health among people living with chronic conditions such as arthritis, diabetes, and heart disease.1 However, despite the health benefits, there are many risks associated with aquatic activities. The Centers for Disease Control and Prevention (CDC) estimates that approximately 3,500 unintentional drownings occur annually in the United States, with children aged one to four having the highest drowning rates.2 Pool chemical injuries in the United States lead to over 4,500 emergency department visits annually, despite being preventable with proper education and safety equipment.3

Outbreaks associated with treated recreational water can be caused by pathogens or chemicals in aquatic venues such as pools, hot tubs, water playgrounds, or other artificially constructed structures that are intended for recreational or therapeutic purposes. For the pseriod 2015-2019, public health officials from 36 states and the District of Columbia (DC) voluntarily reported 208 outbreaks associated with treated recreational water. Almost all (199; 96%) of the outbreaks were associated with public (nonbackyard) pools, hot tubs, or water playgrounds. These outbreaks resulted in at least 3,646 cases of illness, 286 hospitalizations, and 13 deaths. Among the 155 (75%) outbreaks with a confirmed infectious etiology, 76 (49%) were caused by Cryptosporidium (which causes cryptosporidiosis, a gastrointestinal illness) and 65 (42%) by Legionella (which causes Legionnaires' disease, a severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms). Cryptosporidium accounted for 2,492 (84%) of 2,953 cases resulting from the 155 outbreaks with a confirmed etiology. All 13 deaths occurred in persons affected by a Legionnaires' disease outbreak. Among the 208 outbreaks, 71 (34%) were associated with a hotel (i.e., hotel, motel, lodge, or inn) or a resort, and 107 (51%) started during June-August. Implementing recommendations in CDC's Model Aquatic Health Code (MAHC) (1) can help prevent outbreaks associated with treated recreational water in public aquatic venues.

Hurricanes and other natural disasters leave behind multifaceted and complex environmental challenges that may contribute to adverse health outcomes, such as increased potential for exposure to vector-borne disease. Through an incident management system tailored for the Centers for Disease Control and Prevention (CDC), the National Center for Environmental Health/Agency for Toxic Substances and Disease Registry (NCEH/ATSDR) fulfills a leadership role in facilitating the agency's natural disaster emergency response activities through coordination with other CDC programs, liaising with other government agencies and impacted jurisdictions, and responding to requests for technical assistance. On the ground, NCEH/ATSDR deploys environmental health (EH) practitioners who provide consultation and inform mosquito control efforts from a systematic perspective. In the wake of recent hurricanes, NCEH staff mobilized to manage critical elements of the responses and to provide assets for addressing environmental hazards and conditions that contributed to the presence of mosquitoes. In this article, we describe NCEH/ATSDR's emergency response roles and responsibilities, interactions within the national emergency response framework, and provision of EH technical assistance and resources, particularly in the context of postdisaster mosquito control.

Swimming and other water-related activities are excellent ways to get the physical activity and health benefits needed for a healthy life. In the United States, we swim and bathe over 300 hundred million times in pools, oceans, lakes, rivers, and hot tubs/spas each year and most of the time it is healthy, safe, and enjoyable. However, there are risks associated with swimming and other recreational water activities. The number of outbreaks associated with recreational water has increased substantially over the last few decades. Drowning, near-drowning and pool chemical injuries continue to occur (See Table 1). This underscores the need to build, maintain, and inspect public pools, hot tubs/spas, and waterparks to help keep bathers and aquatics staff healthy and safe.

Outbreaks associated with fresh or marine (i.e., untreated) recreational water can be caused by pathogens or chemicals, including toxins. Voluntary reporting of these outbreaks to CDC's National Outbreak Reporting System (NORS) began in 2009. NORS data for 2009-2017 are finalized, and data for 2018-2019 are provisional. During 2009-2019 (as of May 13, 2020), public health officials from 31 states voluntarily reported 119 untreated recreational water-associated outbreaks, resulting at least 5,240 cases; 103 of the outbreaks (87%) started during June-August. Among the 119 outbreaks, 88 (74%) had confirmed etiologies. The leading etiologies were enteric pathogens: norovirus (19 [22%] outbreaks; 1,858 cases); Shiga toxin-producing Escherichia coli (STEC) (19 [22%]; 240), Cryptosporidium (17 [19%]; 237), and Shigella (14 [16%]; 713). This report highlights three examples of outbreaks that occurred during 2018-2019, were caused by leading etiologies (Shigella, norovirus, or STEC), and demonstrate the wide geographic distribution of such outbreaks across the United States. Detection and investigation of untreated recreational water-associated outbreaks are challenging, and the sources of these outbreaks often are not identified. Tools for controlling and preventing transmission of enteric pathogens through untreated recreational water include epidemiologic investigations, regular monitoring of water quality (i.e., testing for fecal indicator bacteria), microbial source tracking, and health policy and communications (e.g., observing beach closure signs and not swimming while ill with diarrhea).

BACKGROUND: Environmental health (EH) professionals, one of the largest segments of the public health workforce, are responsible for delivery of essential environmental public health services. The challenges facing these professionals and research needs to improve EH practice are not fully understood, but 26% of EH professionals working in health departments of the United States plan to retire in 5 y, while only 6% of public health students are currently pursuing EH concentrations. OBJECTIVES: A groundbreaking initiative was recently launched to understand EH practice in health departments of the United States. This commentary article aims to identify priority EH practice challenges and related research needs for health departments. METHODS: A horizon scanning approach was conducted in which challenges facing EH professionals were provided by 1,736 respondents working at health departments who responded to a web-based survey fielded in November 2017. Thematic analyses of the responses and determining the frequency at which respondents reported specific issues and opportunities identified primary EH topic areas. These topic areas and related issues informed focus group discussions at an in-person workshop held in Anaheim, California. The purpose of the in-person workshop was to engage each of the topic areas and issues, through facilitated focus groups, leading to the formation of four to five related problem statements for each EH topic. DISCUSSION: EH professionals are strategically positioned to diagnose, intervene, and prevent public health threats. Focus group engagement resulted in 29 priority problem statements partitioned among 6 EH topic areas: a) drinking water quality, b) wastewater management, c) healthy homes, d) food safety, e) vectors and public health pests, and f) emerging issues. This commentary article identifies priority challenges and related research needs to catalyze effective delivery of essential environmental public health services for common EH program areas in health departments. An unprecedented initiative to revitalize EH practice with timely and strategic recommendations for student and professional training, nontraditional partnerships, and basic and translational research activities is recommended. https://doi.org/10.1289/EHP5161.

Pool chemicals are added to water in treated recreational water venues (e.g., pools, hot tubs/spas, and water playgrounds) primarily to protect public health. Pool chemicals inactivate pathogens (e.g., chlorine or bromine), optimize pH (e.g., muriatic acid), and increase water clarity, which helps prevent drowning by enabling detection of distressed swimmers underwater. However, pool chemicals can cause injuries if mishandled. To estimate the annual number of U.S. emergency department (ED) visits for pool chemical injuries, CDC analyzed 2008-2017 data from the National Electronic Injury Surveillance System (NEISS), operated by the U.S. Consumer Product Safety Commission (CPSC). During 2015-2017, pool chemical injuries led to an estimated 13,508 (95% confidence interval [CI] = 9,087-17,929) U.S. ED visits; 36.4% (estimated 4,917 [95% CI = 3,022-6,811]) of patients were aged <18 years. At least 56.3% (estimated 7,601 [95% CI = 4,587-10,615]) of injuries occurred at a residence. Two thirds of the injuries occurred during the period from Memorial Day weekend through Labor Day. This report also describes a toxic chlorine gas incident that occurred at a public pool in New York in 2018. Pool chemical injuries are preventable. CDC's Model Aquatic Health Code (MAHC) is an important resource that operators of public treated recreational water venues (e.g., at hotels, apartment complexes, and waterparks) can use to prevent pool chemical injuries.

Many pool chemicals are used to protect the health and safety of swimmers and aquatics staff. For example, to help prevent outbreaks of infectious diseases, chlorine or bromine is added as a barrier to pathogen transmission. Muriatic (hydrochloric) acid is added to maintain pH at 7.2–7.8. Clarifiers are added to maximize water clarity, which enable lifeguards and others to identify distressed swimmers underwater and help prevent drownings. | | Maximizing the positive public health impact of pool chemicals calls for minimizing the risk of pool chemical injuries. State and local environmental health practitioners are on the frontline of prevention through educating pool operators about pool chemical safety, inspecting on pool code elements that minimize the risk of pool chemical injuries, investigating pool chemical injuries to identify their root cause(s), and informing the development of optimized measures to prevent future events. This month's column looks at pool chemical injuries and how they can be prevented.

Data from the Centers for Disease Control and Prevention (CDC) shows improper maintenance of public spas increases risk for Legionnaires' disease. Legionnaires' disease affects thousands of individuals each year and represents a significant public health burden, with a 10% case fatality rate and an estimated annual hospitalization cost burden of $433 million.1,2 CDC's Model Aquatic Health Code (MAHC) offers critical guidance for reducing the risk of Legionnaires' disease in public aquatic facilities.

From the 1900 San Francisco bubonic plague epidemic to the 2012 Yosemite National Park hantavirus outbreak, rodents have been a feature of the environment and can compromise the public’s health1. In addition to potentially carrying parasites and pathogens, Norway rats, roof rats, and house mice have been destroying infrastructure, infesting houses and businesses, and damaging property for centuries. To this end, the National Association of County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC) performed a profile of nine rodent control programs across the nation, within large local municipalities. The goal of the project was to understand the current capacity of local rodent control programs across the United States, and identify best practices, challenges, and technical assistance needs. | | A majority of the surveyed programs were located in a comprehensive vector control program in the environmental health division of the local health department. However, in New Orleans (LA), the Mosquito, Termite, and Rodent Control Board within the City Department of Homeland Security assumed the operations of the program from the health department as they felt the duties were more aligned with those of the board. A majority of the programs were supported by local funds. Only two programs, Los Angeles County (CA) and Shelby County (TN), are funded by service fees. In Shelby County, the program is fully funded through a State–legislated Vector Control Fee. Overall, funding for a majority of the programs has either decreased or remained the same within the past five years. Of the five programs who noted a decrease in funds, these reductions resulted in significant staffing and activity cuts. For example, in Los Angeles County the program previously addressed rodent complaints from owner-occupied properties for free, but now has a pay-for-service fee.