# Building a Mosaic: An Integrated Approach to Developing Environmental Public Health Regulations as Demonstrated by an Aquatics Code

# 2007 - 2008 

#  Environmental Public Health Leadership Institute Fellow:

#  Pieter A. Sheehan, REHS

*Environmental Public Health Manager;* St. Charles County Government,
Department of Community Health and the Environment

*1650 Boone's Lick Road*

*St. Charles, MO 63301*

*(636) 949-7406*

*sheehp@lphs.dhss.mo.gov*

# 

# Mentor:

### Martin Kalis, MPH

*Public Health Advisor,* Centers for Disease Control and Prevention

# 

# Acknowledgements:

### Gil Copley, MS

*Director,* St. Charles County Government, Department of Community
Health and the Environment

### Nancy Duncan, RN

*Director, Division of Public Health,* St. Charles County Government,
Department of Community Health and the Environment

### Barry McCauley, MA, PhD

*Mosquito Control Program Coordinator,* St. Charles County Government,
Department of Community Health and the Environment

### Joyce Theard, MPA, REHS

![](media/image1.jpeg){width="1.375in"
height="0.6388888888888888in"}*Special Programs Manager,* St. Louis
County, Department of Health

# EXECUTIVE SUMMARY:

A mosaic is defined as a "design made of colored stones inlaid in
mortar". Ordinances, like mortar, are often static by nature. The
process to change or pass an ordinance takes time. And, like the colored
stones of a mosaic, how stakeholders are utilized and existing resources
are used during the development of environmental public health
regulations, dictates a successful outcome and appreciation of the final
product.

The State of Missouri does not have regulations specific to aquatic
centers (pools and spas). Until late 2007, the fastest growing county in
the state, St. Charles County, also did not have regulations
safeguarding the public health and safety of consumers at swimming pools
and spas. Community stakeholders were very interested in reviewing draft
regulatory language that could be considered for passage as a new county
ordinance regulating aquatic centers.

Most environmental public health regulations are passed and implemented
on a local level. In many instances, the federal and state governments
have developed guidance or "model" codes to assist in the development of
local regulations. When developing new environmental public health
regulatory language, consulting these documents is extremely valuable.
What happens, however, when a guidance document does not exist or a
local regulatory agency needs to augment a federal or state document to
meet a certain political environment?

Effective environmental public health regulation at the local level is
best achieved by bringing together different facets, such as:

-   Current practices or norms across the country;

-   Current state requirements or practices; and

-   Local stakeholders' concepts of effective regulatory language: how
    it affects public health and safety, economics, or even politics.

This project applied Systems Thinking to current practices surrounding
pool regulations at a national level to determine how best to implement
an aquatics and recreational code at the county level. The first part of
the implementation process started with developing a draft aquatics
code. The results of this project can be applied to other environmental
public health programs where regulatory language needs to be developed.

# INTRODUCTION/BACKGROUND:

The first recorded presence of Europeans in St. Charles County occurred
in June 1673, when Father Jacques Marquette and his companion Louis
Joliet discovered the muddy waters of the Missouri River flowing into
the Mississippi River. Today, as then, St. Charles County is located at
a point where the Missouri and Mississippi floodplains meet (1). St.
Charles County is a county nearly surrounded by water. Consequently,
water quality and its maintenance is for many a priority issue. In 2007,
an effort to pass a comprehensive aquatics code, regulating public and
semi-public swimming pools and spas was undertaken.

When it comes to the aquatic environment, the fundamental concern of the
environmental public health specialist (EPHS) and a primary mission of
the governmental agencies they work for is the health and safety of the
community that uses pools and spas. The foundation of an enforcement
program is an integrated aquatics code that begins with the approval of
original construction design. Oversight continues with regular facility
inspections of the aquatic operation. Many environmental public health
agencies check for the following issues:

-   Pool/Spa is free of material, visible dirt, and algae.

-   Deck has a minimum clearance around the pool/spa.

-   The pool/spa finish is intact and in good repair.

-   Depth markings are intact and in proper locations.

-   Handrails, grab-rails and ladders are secure.

-   Gutter drains are covered with a fully intact grate and no
    protrusions are present.

-   Skimmers have an intact weir in place. Deck covers are in place and
    properly secured.

-   Underwater lights are in working order and properly in place with no
    crevices between the niche and light fixture.

-   Diving boards are secured and slip resistant.

-   The *shepherd's hook(s)* attached to a 16-foot non-extendable pole
    is fully accessible and easily seen.

-   The 18-inch diameter lifesaving ring with sufficient rope attached
    to reach all parts of the pool is fully accessible and easily seen.

-   A floating safety line is in place two feet toward the shallow end
    before the slope break.

-   The required pool/spa rules are posted in the mandatory location(s).

-   Sanitary facilities have the appropriate supplies and are properly
    maintained.

-   There is an approved test kit on site.

-   Disinfection feeders are in place, and are properly operational (2).

Currently, there is no national standardized aquatic code in the
tradition of the Food and Drug Administration's Food Code. Developing
regulatory language for consideration as an ordinance can be challenging
for a local public health agency. There are standards available
(*American National Standard for Public Swimming Pools* as an example)
that some argue lean too heavily toward building standards and lack
comprehensive public health safety oversight. Additionally, there are
numerous pool codes that have been passed at the local and state level
that can be reviewed.

Referencing the aquatic code of a sister agency from another part of the
country can become problematic. The reason stems from how the
environment actually impacts the aquatic operation. As an example:

-   Areas in the south and west parts of the country have longer pool
    seasons than the Midwest, eastern and northern parts of the US.

-   Pool chemistry is affected by direct sunlight. The west has much
    more direct sunlight than other parts of the county.

-   The number of pools in the warmer parts of the country far exceeds
    those in the middle, eastern and northern parts of the county. With
    more pools, the number of people using each pool maybe less.

-   The geology of different areas of the country effecst the design and
    operation of pools and spas (3).

The FDA Food Code addresses controls for risk factors in food
establishments by establishing five key public health interventions to
protect consumer health based on epidemiological outbreak data that
identifies five major risk factors. These factors are:

-   Improper holding temperatures,

-   Inadequate cooking, such as undercooking raw shell eggs,

-   Contaminated equipment,

-   Food from unsafe sources, and

-   Poor personal hygiene (4)

Without epidemiological data as background, using numerous state and
local codes the following six (6) factors that lead to an unsafe
aquatics environment were utilized as steering points when developing
the St. Charles County draft aquatics code.

These six (6) factors are labeled as " Six factors that lead to an
unsafe aquatics environment" . When developing the draft regulatory
language that would be considered as the St. Charles County Aquatics
Code, these factors were constantly referred to as a guide.

####### ***Problem Statement:*** 

Development of a national pool (aquatic) code is currently underway at
the Centers for Disease Control and Prevention. The purpose of this
project was to give insight to the development of a local county aquatic
code without the assistance of a national integrated pool code that has
gone through the rigors of the federal development process. The main
steering mechanism as other state and local codes were referred to in
the development of St. Charles County's Aquatic Code was the
introduction of the following:

**Six Factors that Lead to an Unsafe Aquatics Environment**

1.  Poor facility design and maintenance,

2.  Inability to get help in an emergency,

3.  Lack of safety equipment,

4.  Poor user hygiene,

5.  Inadequate water chemistry, and

6.  Inadequate barrier security.

In order to address the myriad of complex requirements that are
contained in other aquatic codes and to decide on what would most
benefit including into St. Charles County's draft, these six factors
were used to help decided the public health rationale for inclusion.

####### ***Behavior Over Time Graph:***

####### ![](media/image2.wmf){width="8.98611111111111in" height="6.1305555555555555in"} 

####### ***Causal Loop Diagrams and applicable archetypes:***

####### 

####### ***10 Essential Environmental Health Services:***

The table below describes how the development of an integrated aquatics
code in St. Charles County fulfilled areas of the *10 Essential
Environmental Health Services*.

  ------------------------------------------- --------------- ----------------
  **Core Public Health Function:**            **Essential     **How this
                                              Environmental   project is
                                              Health          enhancing this
                                              Service:**      service:**

  Assessment                                  Monitor         The aquatic
                                              environmental   ordinance will
                                              and health      serve as a
                                              status to       platform to
                                              identify and    identify and
                                              solve community help with
                                              environmental   solutions to
                                              health          problems that
                                              problems.       effect public
                                                              health and
                                                              safety.

                                              Diagnose and    
                                              investigate     
                                              environmental   
                                              health problems 
                                              and health      
                                              hazards in the  
                                              community.      

  Policy Development                          Inform, educate Achieved through
                                              and empower     an education
                                              people about    requirement in
                                              environmental   the aquatics
                                              health issues.  code that
                                                              operators of
                                                              aquatic centers
                                                              obtain a
                                                              nationally
                                                              recognized
                                                              training
                                                              certification.

                                              Develop         Development and
                                              policies and    implementation
                                              plans that      of aquatic code
                                              support         was achieved
                                              individual and  through a
                                              community       collaborative
                                              environmental   effort of pool
                                              health efforts. builders, pool
                                                              operators and
                                                              consumers.

  Assurance                                   Enforce laws    Origination of
                                              and regulations an aquatic code
                                              that protect    to protect
                                              health and      public health.
                                              ensure safety.  
  ------------------------------------------- --------------- ----------------

![](media/image3.png){width="2.0493055555555557in"
height="1.9493055555555556in"}

*National Goals Supported*

+---------------+----------------+-------------+-----------------------+
| **CDC Health  |                |             | **How this project    |
| Protection    |                |             | supports the Goal:**  |
| Goal**        |                |             |                       |
+---------------+----------------+-------------+-----------------------+
| **Healthy     | **[Healthy     | [Objective  | Through a             |
| People in     | Travel &       | 65.]{       | collaborative         |
| Healthy       | Recreation]{   | .underline} | relationship between  |
| Places:** The | .underline}**: | Promote     | community and         |
| places where  | Ensure that    | healthy,    | department resources, |
| people live,  | environments   | safe, and   | passage of county     |
| work, learn,  | enhance health | accessible  | aquatic code will     |
| and play will | and prevent    | e           | promote safe and      |
| protect and   | illness and    | nvironments | healthy pool/spa      |
| promote their | injury during  | for travel, | environments.         |
| health and    | travel and     | tran        |                       |
| safety,       | recreation.    | sportation, |                       |
| especially    |                | and         |                       |
| those at      |                | recreation  |                       |
| greater risk  |                |             |                       |
| of health     |                |             |                       |
| disparities.  |                |             |                       |
+---------------+----------------+-------------+-----------------------+
|               | **[Healthy     | [Objective  | By inspecting aquatic |
|               | Institutions:] | 59.]{       | and recreational      |
|               | {.underline}** | .underline} | environments          |
|               | Increase the   |             | prevention of         |
|               | number of      | Prevent     | infectious disease    |
|               | institutions   | infectious  | will be minimized.    |
|               | that provide   | diseases    |                       |
|               | safe, healthy, | and their   |                       |
|               | and equitable  | c           |                       |
|               | environments   | onsequences |                       |
|               | for their      | among       |                       |
|               | residents,     | people in   |                       |
|               | clients, or    | in          |                       |
|               | inmates.       | stitutional |                       |
|               |                | settings.   |                       |
+---------------+----------------+-------------+-----------------------+
|               | **[Healthy     | [Objective  | Having a countywide   |
|               | Schools:]      | 48.]{       | inspection program of |
|               | {.underline}** | .underline} | aquatic operations in |
|               | Increase the   |             | county schools will   |
|               | number of      | Promote     | ensure safe and       |
|               | schools that   | safe,       | healthy pool/spa      |
|               | protect and    | healthy and | environments.         |
|               | promote the    | accessible  |                       |
|               | health, safety | physical    |                       |
|               | and            | e           |                       |
|               | development of | nvironments |                       |
|               | all students,  | in schools. |                       |
|               | and protect    |             |                       |
|               | and promote    |             |                       |
|               | the health and |             |                       |
|               | safety of all  |             |                       |
|               | staff.         |             |                       |
|               | (e.g.-healthy  |             |                       |
|               | food vending,  |             |                       |
|               | physical       |             |                       |
|               | activity       |             |                       |
|               | programs)      |             |                       |
+---------------+----------------+-------------+-----------------------+

Figure 1: Demonstrates how project supports CDC Health Protection Goals.

<http://www.cdc.gov/about/goals/factSheet.htm>

+--------------------------------------------+-------------------------+
| **Goal/Objective**                         | **How this project      |
|                                            | supports the            |
|                                            | Goal/Objective:**       |
+--------------------------------------------+-------------------------+
| **Goal I. Build Capacity.** *Objective     | The project is          |
| I-B: Support, evaluate, and disseminate    | primarily focused on    |
| the results of new demonstration programs, | developing regulatory   |
| best practices, and CDC-supported projects | language for            |
| designed to improve livability and to      | consideration as a      |
| prevent and control environmentally        | county ordinance        |
| related illness.*                          | through an integrated   |
|                                            | and collaborative       |
| -   Activity I-B-3: Promote institutional  | manner of community     |
|     and strategic changes to foster        | stakeholders. It is     |
|     ongoing coordinated efforts with       | important to remember   |
|     strategic partners and other           | that the aquatic code   |
|     stakeholders to implement and evaluate | would be a new          |
|     environmental interventions to improve | ordinance in the        |
|     health and well-being for urban and    | county.                 |
|     rural residents.                       |                         |
+--------------------------------------------+-------------------------+
| **Goal II. Support Research.** *Objective  | This project through a  |
| II-D: Implement environmental public       | collaborative passage   |
| health service demonstrates and evaluates  | of a countywide         |
| in the built and natural environments that | aquatics code leads to  |
| lead to healthier communities.*            | improved community      |
|                                            | public health by        |
| -   Activity II-D-1: Support demonstration | safeguarding pool/spa   |
|     projects that describe strategic       | operations and the      |
|     interventions designed to improve      | patrons that use them.  |
|     community health.                      |                         |
|                                            | Project goal is passage |
| -   Activity II-D-2: Evaluate best         | of an aquatics          |
|     practices and gaps related to laws,    | ordinance in a county   |
|     ordinances, and regulations that       | where there currently   |
|     affect environmental public health     | is not one.             |
|     service delivery and practice.         |                         |
+--------------------------------------------+-------------------------+
| **Goal VI. Create strategic                | This project integrated |
| partnerships.** *Objective IV-B: Support   | a system of community   |
| educational approaches and models of best  | partnership through a   |
| practices to gain community support and    | code development        |
| participation in addressing environmental  | process that emphasized |
| public health service issues, concerns,    | a educational           |
| and best models to organize, deliver, and  | foundation through      |
| market environmental public health         | mandated operator's     |
| services.*                                 | training .              |
|                                            |                         |
| -   Activity IV-B-1: Support activities    |                         |
|     and projects that demonstrate          |                         |
|     effective methods for interacting with |                         |
|     environmental public health            |                         |
|     stakeholders.                          |                         |
|                                            |                         |
| -   Activity IV-B-2: Recommend and         |                         |
|     disseminate the best environmental     |                         |
|     public health service models to engage |                         |
|     and empower local communities.         |                         |
+--------------------------------------------+-------------------------+

Figure 2: Demonstrates how project supports National Strategy to
Revitalize Environmental

Public Health Services.

<http://www.cdc.gov/nceh/ehs/Docs/nationalstrtegy2003.pdf>

+---------------------------------------------+------------------------+
| **Core Competency for Environmental Health  | **How this project     |
| Practitioner:**                             | uses the Environmental |
|                                             | Health Practitioner    |
|                                             | core competency;**     |
+---------------------------------------------+------------------------+
| > **A. Assessment.**                        | The development of an  |
| >                                           | aquatics code in St.   |
| > *A1. Research: The capacity to identify   | Charles County         |
| > and compile relevant information to solve | required the           |
| > a problem, and the knowledge of where to  | environmental health   |
| > go to obtain the relevant information.*   | practitioner (EPHS) to |
| >                                           | research extensively   |
| > *A3. Evaluation: The capacity to evaluate | on other               |
| > the effectiveness or performance of       | jurisdictional         |
| > procedures, interventions, and programs.* | pool/spa codes.        |
|                                             |                        |
|                                             | EPHS had to do         |
|                                             | extensive research on  |
|                                             | national and state     |
|                                             | standards pertaining   |
|                                             | to pool and spa        |
|                                             | operations.            |
|                                             |                        |
|                                             | EPHS had to research   |
|                                             | current inspection     |
|                                             | protocols in aquatic   |
|                                             | regulatory programs in |
|                                             | other jurisdictions.   |
+---------------------------------------------+------------------------+
| > **B. Management.**                        | This project uses the  |
| >                                           | EPHS competency to     |
| > *B1. Problem Solving: The capacity to     | determine the nature   |
| > understand and solve problems.*           | of problems faced in   |
|                                             | the aquatic            |
|                                             | environment and        |
|                                             | delineate them in      |
|                                             | sound regulatory       |
|                                             | language.              |
+---------------------------------------------+------------------------+
| > **C. Communication.**                     | This project (aquatic  |
| >                                           | code) has a heavy      |
| > *C1. Education: The capacity to use the   | emphasis on operator   |
| > environmental health practitioner\'s      | education by mandating |
| > front-line role to effectively educate    | uniform operator       |
| > the public on environmental health        | training in pool       |
| > issues.*                                  | operations and         |
| >                                           | bloodborne pathogens.  |
| > *C2. Communication: The capacity to       |                        |
| > effectively communicate risk and exchange | Through a mandate of   |
| > information with colleagues, other        | clear signage in       |
| > practitioners, clients, policy-makers,    | aquatic centers and    |
| > interest groups, media, and the public    | ongoing communication  |
| > through public speaking, print and        | between operators,     |
| > electronic media, and interpersonal       | consumers and          |
| > relations.*                               | department.            |
+---------------------------------------------+------------------------+

Figure 3: Demonstrates how project supports Environmental Health
Competency Project.

<http://www.apha.org/programs/standards/healthcompproject/corenontechnicalcompetencies.htm>

####### ***Project Logic Model:***

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

####### ***Program Goal***

Ensure public health and safety of aquatic and recreational facilities\*
environment.

####### ***Health Problem***

There are no common set of standards county-wide to insure public health
and safety of aquatic and recreational environments.

####### ***Outcome Objective***

By August 1, 2007 county legislative body will consider and hopefully
pass a uniform set of standards governing aquatic and recreational
facilities.

####### ***Determinant***

The number of compliance inspections that result in no critical
violations.

####### ***Impact Objective***

By January 1, 2008, majority of aquatic facilities (90%) pass compliance
inspections specific to health, safety and facility management conducted
by department.

####### ***Contributing Factors***

1.  Lack of uniform training of aquatic facility staff specific to pool
    and spa maintenance and water chemistry and bloodborne disease
    transmission.

2.  Inability of public to get relief from aquatic centers and
    recreational facilities that have unsafe environments.

3.  Inconsistent facility management (aquatic and recreational) due to
    lack of uniform standards.

4.  Lack of public awareness on proper aquatic and recreational
    environmental health.

####### ***Process Objectives***

> 1a. By September 3, 2008, three nationally certified pool operator
> classes will be offered in the county.
>
> 1b. By September 3, 2008, department will offer 2 bloodborne pathogen
> training classes.
>
> 2\. Ensure placards are present at all aquatic and recreational
> facilities giving a phone number to department complaint line.
>
> 3\. By September 3, 2008: Policy and procedures (codebook, inspection
> form, uniform inspection procedures, etc.) developed.
>
> 4\. By September 3, 2008, ensure all aquatic and recreational
> facilities have posted public health and safety signs as required by
> new code.

\*Recreational Facilities mean **tanning salons and fitness centers**
(gyms, wrestling rooms, weight rooms)

# METHODOLOGY:

####### ***Events and Activities***

> 1a. By September 3, 2008, three nationally certified pool operator
> classes will be offered in the county.
>
> **Event:** *Certified Pool Operator's Course* offered.
>
> **Activities** Recruit certified CPO instructors to offer class in
> county.
>
> 1b. By September 3, 2008, department will offer 2 bloodborne pathogen
> training classes.
>
> **Event:** Aquatic Bloodborne Training classes developed and offered
> by Program.
>
> **Activities:** Have staff obtain training as Bloodborne Pathogen
> Instructors.
>
> Develop bloodborne training class (handout, powerpoint, etc.)
>
> 2\. Ensure placards are present at all aquatic and recreational
> facilities giving a phone number to department complaint line.
>
> **Event:** Implement uniform citizen complaint program.
>
> **Activities:** Design a complaint placards (consider using food
> facility placards).
>
> Obtain a direct complaint line into Environmental Public Health
> Program.
>
> With assistance of public information officer, determine best outreach
> to "advertise" complaint number.
>
> 3\. By September 3, 2008: Policy and procedures (codebook, inspection
> form, uniform inspection procedures, etc.) developed.
>
> **Event:** Aquatic and Recreational Facilities Code passes and
> compliance program starts.
>
> **Activities:** Draft inspection forms.
>
> Draft documents to assist facilities in understanding the new code
> (code reference sheet).
>
> Uniform inspections conducted by environmental public health
> specialists.
>
> 4\. By September 3, 2008, ensure all aquatic and recreational
> facilities have posted public health and safety signs as required by
> new code.
>
> **Event:** Code passes and sign requirements become mandatory.
>
> **Activities:** Supply facilities with information on signage
> requirements.
>
> Update department website to include aquatic and recreational facility
> education information.

# RESULTS:

As a result of this project, significant work was completed on
implementing an aquatics code in St. Charles County, Missouri.

1.  Research and development of a draft code that fit current national
    standards yet met the expectations of local stakeholders.

2.  Completion of draft regulatory language that could be offered as an
    aquatics ordinance.

3.  Passage of the *St. Charles County Aquatic and Recreational
    Facilities Code* in August of 2007.

4.  Ideas generated could guide process of an aquatics code in other
    areas of the country at a federal, state or local level.

# CONCLUSIONS:

Effective environmental public health regulation at the local level is
best achieved by bringing together different facets with a connection to
the issue. This project applied Systems Thinking to current practices
surrounding pool regulations at a national level to determine how best
to implement an aquatics and recreational code at the county level. A
code was passed by the legislative body of the St. Charles County
Government and now the following steps are currently underway:

-   Development of program elements to implement regulatory activities.

-   Education outreach to operators and consumers.

-   Outreach to municipalities in St. Charles County for adoption of
    county aquatics and recreational facilities code.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Pieter A. Sheehan***

I am a natural skeptic! When this journey started I was worried if I
could meet the expectations of the Institute. The past year has flown by
and one thing I can say is the Institute has far exceeded any
expectations I had of it. This experience has been life-enriching and
has left me with tools that will allow me to excel as a leader in the
field of environmental health. I would like to thank EPHLI for the
opportunity to meet peers from all over the United States and experience
being an EPHLI fellow.

# ABOUT THE EPHLI FELLOW

Pieter A. Sheehan has been with the St. Charles County, Department of
Community Health and the Environment in St. Charles, Missouri since
October, 2006. Prior to St. Charles County he was with St. Louis County
Department of Health in Clayton, Missouri, Monterey County Department of
Health in Salinas, California and Maricopa County Department of
Environmental Services in Phoenix, Arizona. He started as an air quality
inspector with Maricopa County moving on to become a senior
environmental health specialist in solid and hazardous waste management
in Monterey County. Mr. Sheehan moved to the Midwest and joined St.
Louis County as a supervising environmental public health specialist in
consumer protection. He currently is the manager of the environmental
public health program with St. Charles County.

Pieter has a BS in Microbiology from the University of Arizona in
Tucson, Arizona. He is currently a registered environmental health
specialist (sanitarian) in the states of Arizona, California, and
Missouri and also holds a national REHS certification with the National
Environmental Health Association.

# REFERENCES

1.  Ehlmann, Steve, *Crossroads: A History of St. Charles County,
    Missouri*, 2004, Lindenwood University Press, St. Charles, Missouri.

2.  Ford, Ronald l., *Certified Pool-Spa Operator Handbook*, 2007,
    National Swimming Pool Foundation, Colorado Springs, Colorado.

3.  Based on conversations with Jim Bastian, President of Westport Pools
    and Midwest Pool Management, Maryland Heights, Missouri.

4.  U.S. Department of Health and Human Services, *FDA 2005 Food Code*,
    U.S. Public Health Service, College Park, Maryland.