Copyright Recreational Water Illness and Aquatic Facility Related Events Associated with Swimming Pool Chemicals. Outline

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1 Recreational Water Illness and Aquatic Facility Related Events Associated with Swimming Pool Chemicals Michele Hlavsa, RN, MPH Healthy Swimming Division of Parasitic Diseases Centers for Disease Control & Prevention Outline Examine sources of data on pool chemical associated injuries Characteristics of existing surveillance systems Epidemiologic data Examples What are the data telling us? Definitions for This Talk Recreational water venues Include swimming pools, wading pools, spas, waterslides, interactive fountains, and wet decks Swimming pool chemicals Include but not limited to calcium hypochlorite, sodium hypochlorite, dichlor, trichlor, hypobromous acid, hydrogen peroxide, and muriatic acid Include disinfection byproducts Chloramines or combined chlorines Copyright

2 Swimming is an all-american sport, fun and great exercise, but swimming can also lead to illness and injuries National Poison Data System, U.S. poison centers Aggregate data 9,573 human exposures to single pool or aquarium chemical 39% (3,775) person <6 years of age 97% (9,287) unintentional 19% (1,781) persons sought healthcare treatment Source: Bronstein AC et al Annual Report of the American Association of Poison Control Centers National Poison Data System (NPDS).: 25 th Annual Report. Clin Toxicol 46(10): Report.pdf Reports of Human Exposure to Swimming Pool or Aquarium Chemicals United States, 2007 Generic Substance No. of Single Exposures Age <6 years Unintentional Algicide 1,884 32% (607) 98% (1,839) Chlorine water/shock 3,319 20% (663) 97% (3,212) treatment Bromine water/shock treatment % (43) 93% (105) Source: Bronstein AC et al Annual Report of the American Association of Poison Control Centers National Poison Data System (NPDS).: 25 th Annual Report. Clin Toxicol 46(10): Report.pdf Copyright

3 U.S. Consumer Product Safety Commission National Electronic Injury Surveillance System (NEISS) Visits ~100 hospitals emergency department (ED) across the United States Injuries linked to consumer products Individual records Occurrences at home or public recreational water venues Swimming pool chemicals (code=938) Source: US Consumer Product Safety Commission. NEISS: Estimates Query Builder. Accessed October 9, Emergency Department (ED) Visits for Injuries Associated with Pool Chemicals United States, National Estimates 7,500 6,000 4,500 3,000 1,500 National estimates of ED visits 95% confidence intervals Year Source: US Consumer Product Safety Commission. NEISS: Estimates Query Builder. Accessed October 9, Injuries Associated with Swimming Pool Chemicals for which Patients Sought ED Treatment United States, 2007 Injury Estimate 1 ED Visits 1 Poisoning 2 40% (1,844) 41% (47) Dermatitis/ Conjunctivitis 27% (1,245) 27% (31) Chemical burn 18% (820) 14% (16) Other 3 16% (725) 18% (21) 1. National estimate=4,635; NEISS ED visits= Includes inhalation of vapors, fumes, or gases 3. Includes but is not limited to contusion/abrasion, foreign body, laceration, internal organ injury, strain/sprain, and submersion Source: US Consumer Product Safety Commission. NEISS: Estimates Query Builder. Accessed October 9, Copyright

4 Epidemiologic Factors & Injuries Associated with Swimming Pool Chemicals for which Patients Sought ED Treatment United States, 2007 Factor Estimate 1 ED Visits 1 Age years 43% (1,975) 34% (39) Male 55% (2,537) 57% (65) White 2 52% (2,429) 50% (57) Summer 3 58% (2,698) 63% (73) Home 4 43% (2,010) 44% (51) 1. National estimate=4,635; NEISS ED visits= Missing data: 24% (22) of patients (2006), 34% (39) of patients (2007) 3. Friday before Memorial Labor Day 4. Missing data: 20% (18) of patients (2006), 40% (46) of patients (2007) Source: US Consumer Product Safety Commission. NEISS: Estimates Query Builder. Accessed October 9, Common Themes of Injuries Linked to Swimming Pool Chemicals Opened container of chlorine Splashed swimming pool chemical in own face or child s Pre-dissolved chemical Mixed different swimming pool chemicals, fertilizer and chlorine Swam in over-chlorinated pool Chloramines or combined chlorines? Made chlorine bomb Source: US Consumer Product Safety Commission. NEISS: Estimates Query Builder. Accessed October 9, Centers for Disease Control & Prevention Waterborne Disease Outbreak (WBDO) Surveillance System Reports on investigations by health departments Reports of WBDO associated with recreational water Aquatic facility related health event not associated with recreational water Single cases of chemical/toxin poisoning, primary amebic meningoencephalitis, wound infections Copyright

5 Surveillance Summary Environmental Health Specialist Network Water Program MN, NY, TN Retrospective review identified 30 WBDOs associated with recreational water 32 aquatic facility related health events All in NY Source: Yoder JS et al MMWR 57(SS-9):1 38. WBDO Associated with Recreational Water >2 persons epidemiologically linked by Exposure to recreational water Time Illness Evidence must implicate water or volatilization of water-associated compound into water s surrounding air Aquatic Facility Associated Health Events Single cases of chemical or toxin poisoning Water or air quality data indicate contamination Single cases or outbreaks associated with contaminated aquatic facility air Not associated with the recreational water Copyright

6 Pool Chemical Associated Health Events New York, (N=36) 31 (86%) where pool not central focus School or college, membership club, housing complex or hotel, institution 21 (58%) during summer swim season 1 31 (86%) caused by generated toxic chlorine gas 24 (77%) resulted from mixing chlorine and acid 1. Memorial Day through Labor Day Chemical Mixing Accident/Chlorine Gas Exposure New York, 1988 Context Recirculation pump shut down after power outage but chlorine/ph control feed pumps continue running Recirculation pump reset and concentrated chlorine and acid surged into pool and release chlorine gas Magnitude 21 children taken to hospital Emergency response: 7 ambulances, 2 paramedic units, 11 police officers Outcome County and state pool codes revised Source: CDC MMWR 58(18): Chemical Mixing Accident/Chlorine Gas Exposure New York, 1995 Context Order 5-gallon chlorine containers but receive 5- gallon acid containers Did not read label before use and mix acid and chlorine Magnitude 2 custodians and 98 students taken to hospital Response: multiple government agencies Outcome Health education campaign focused on safe chemical and storage practices Source: CDC MMWR 58(18): Copyright

7 Disinfection Byproducts Chloramines or Combined Chlorines Form in water when free chlorine combines with urine and sweat Cause ocular irritation Evaporate from water and enter air Produce strong smell Cause respiratory irritation, possibly asthma Linked to poorly maintained indoor pools or poor ventilation Except extremely high bather load Chloramines Nebraska, 2006 Context Child admitted to pediatric ICU after swimming in indoor pool at hotel on Christmas Day Magnitude 23 other persons ill with burning/watery eyes, sore throat, and cough Findings Risk factors: entering pool area, swimming in pool 26 violations: 0.8 parts per million (ppm), free chlorine, 4.2 ppm combined chlorine, ph 3.95 Pool operator untrained/uncertified Source: Buss et al MMWR 56(36): Chloramines Indianapolis, 2006 Context >1,000 athletes at U.S. Swimming Nationals Competitors experienced breathing problems and headaches and had red, watery eyes Investigation All exhaust fans shut down on first day Outcome Brendan Hansen: If you go in the pool for 10 minutes, it kills you. Right now, I can t breathe in deep because I know I ll cough. Missed best time in 200 meter breaststroke by almost 2 seconds Source: Copyright

8 Michael Phelps on Peeing in the Pool Chemical Exposure New York, 1996 Context Mixed granular chlorine and water in bucket in filter room Developed cough and difficulty breathing Magnitude 1 person transported to hospital by Mobile Life Support Unit Findings Did not use face mask Not listed in safety plan under chemical handling Source: Yoder JS et al MMWR 57(SS-9):1 38. Chemical Mixing Accident/Chlorine Gas Exposure New York, 2002 Context Clamp on chlorine feeder came loose Apartment complex pool Chlorine sprayed all over filter room and onto muriatic acid Chlorine gas released Magnitude 1 person taken to hospital Findings Chemicals not segregated Source: Yoder JS et al MMWR 57(SS-9):1 38. Copyright

9 Chemical Exposure New York, 1998 Context Chlorinator clogged and chlorine splashed in eye when hose to chlorinator disconnected Hotel pool Magnitude 1 person taken to hospital Findings Untrained personnel attempted to repair equipment Chlorine feed pump not turned off No personal protective equipment (PPE) available Safety plan well written but not followed Source: Yoder JS et al MMWR 57(SS-9):1 38. What Are These Data Telling and Not Telling Us? Injuries associated with swimming pool chemicals common Snapshots of related injuries incomplete Magnitude? What events or outbreaks are we missing? Can We Prevent These Injuries? Yes! Balance competing risk reduction plans Preventing these injuries versus traditional recreational water illness Educate/train all public pool operators Including those in settings where pool is not central focus (e.g., school or hotel) Educate residential pool owners Using residential pools not protective Copyright

10 Preventing Injuries Associated with Swimming Pool Chemicals Avoid chemical mixing Keep swimming pool chemicals dry Use personal protective equipment (PPE) Source: Environmental Proctection Agency Chemical Safety Alert: Safe Storage and Handling of Swimming Pool Chemicals Design Install device that automatically deactivates chemical feed pumps when recirculation pump shuts down Secure chemicals away from children and animals Include secondary (spill) containment features Chemical Storage & Handling Read and follow the manufacturer s directions Store in conditions (temperature and humidity) within manufacturer s guidelines Use only chemicals in manufacturer s original, labeled container Wear appropriate PPE Do not mix chlorine products with each other, with acid, or any other substances Copyright

11 Maintenance and Repair Ensure only properly trained personnel service equipment Close pool to swimmers before starting maintenance or repair Reopen to swimmers after equipment restarted Turn off chlorine/ph control feed and recirculation systems before servicing Maintain feed and recirculation systems according to manufacturer s guidelines Set up preventive maintenance program Pool Operator Training Topics Reading labels for swimming pool chemicals and corresponding Material Safety Data Sheets Incompatibility of certain chemicals Safe chemical storage and handling practices Use of PPE while handling chemicals Emergency Response Plan Develop plan which includes Chemical-mixing accident response Spill-cleanup plan Clear chain of command listing contact numbers and alternates Train aquatics staff on procedures Ensure copy of plan accessible in case of evacuation Call emergency responders and do not attempt to fix the problem Copyright

12 Snapshots of Injuries Incomplete Collect data systematically, nationally Look for alternative data sources Is someone else collecting similar or supporting data? NY data from chemical incident reports Agency for Toxic Substances and Disease Registry Hazardous Substances Emergency Events Surveillance (HSEES) Goal Reduce morbidity and mortality resulting from hazardous substances events Collect and analyze data about acute release of hazardous substances and threatened releases National Outbreak Reporting System: Waterborne Disease Outbreak Reporting Copyright

13 Prevention & Education Materials Will be available for free late June/early July thanks to generous financial support of the American Chemistry Council Chloramines Require Activist Swimmers Follow the triple A s Awareness Action Advocacy Awareness Visit See webpage on irritants Practice good hygiene: limit amount of urine and sweat in the water Shower with soap thoroughly before entering the water Take regular bathroom breaks Copyright

14 Action Ask the pool operator if Chlorine and ph levels checked at least 2 times per day More often when the pool is heavily used Combined chlorine levels calculated regularly Combined chlorine = Total chlorine free chlorine Most states allow up to ppm combined chlorine Talk to fellow swimmers about combined chlorines Advocacy Encourage operators to take steps known to decrease combined chlorine levels Require patrons to take regular bathroom breaks Add in-line ultraviolet radiation Super-chlorinate Increase free chlorine level to 10 times combined chlorine level under well-ventilated conditions Increase/improve ventilation Advocate for making measuring combined chlorines standard part of pool inspections Model Aquatic Health Code (MAHC) Improve public health in aquatics facilities Provide uniform guidelines Design, construction, operation, and maintenance Data-driven, best practices based Address in technical committees Operator Training Ventilation & Air Quality Monitoring & Testing Chemical Storage & Handling Facility Design & Construction Emergency Response/Communication Copyright

15 Effect Change and Promote Healthy Swimming Volunteer to participate on a technical committee To Participate or Not to Participate? Reduce burden on individual health departments Ensure voice is heard Additional acts like Virginia Graeme- Baker Pool and Spa Safety Act? 1. Beach MJ J Environ Health 71(9):36 7. Factsheets Healthy Swimming All documents 2002can be downloaded at: w w w. c d c. g o v / h e a l t h y s w i m m i n g Posters CORE Copyright

16 Required Disclaimer from the Department of Health and Human Services (Please Interpret as You See Fit) The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy. Acknowledgements CDC/NCZVED/DPD Michael Beach Jonathan Yoder Mike Arrowood CDC/NCEH/EHSB Charles Otto NY State Dept. of Health Doug Sackett Eric Wiegert Jessica Egan Dave Nicholas American Chemistry Council Jeff Sloan ARCH Chemical Peggy Geimer Mickey Norsworthy Jerry Pierrottie Copyright