#  Creating a Comprehensive Public Swimming Pool and Water Attraction Program to Provide Safe Water Recreation in Wisconsin 

# 2005 - 2006 

# Environmental Public Health Leadership Institute Fellow:

# 

# Tracynda Davis, M.P.H.

*Program Manager*

*Food Safety and Recreational Licensing*

*Division of Public Health*

*Wisconsin Department of Health and Family Services*

*1 W. Wilson Street*

*P.O. Box 2659*

*Madison, WI 53701*

*608-266-8294*

[*davistl@dhfs.state.wi.us*](mailto:davistl@dhfs.state.wi.us)

# 

# Mentor:

### **CDR Mark Miller, R.S., M.P.H.**

*Captain, U.S. Public Health Service*

*Senior Environmental Health Specialist*

*National Center for Environmental Health*

*Centers for Disease Control and Prevention*

> ![](media/image1.jpeg){width="1.3756944444444446in"
> height="0.6368055555555555in"}

# 

# Acknowledgements:

### 

### **Greg Pallaske, R.S., M.S.**

### *Chief, Food Safety and Recreational Licensing* 

*Wisconsin Department of Health and Family Services*

**Michael Beach, Ph.D.**

## Chief, Water and Environment Activity

*Division of Parasitic Diseases*

*National Center for Infectious Diseases*

*Centers for Disease Control and Prevention*

#### Charles Otto, III, R.S.

*Captain, U.S. Public Health Service*

*Team Leader, Environmental Health Services Branch*

*Division of Emergency and Environmental Health Services*

*Centers for Disease Control and Prevention*

![](media/image1.jpeg){width="1.3756944444444446in"
height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

Wisconsin is home to approximately 4,000 public swimming pools and water
attractions and had over 2.9 million people visit the Wisconsin Dells
area in 2004 in search of water recreation. ^1,2^ The number of patrons
visiting these facilities has been increasing, as well as the number of
new water attractions and slides that do not currently fit in existing
regulations. Waterslides have become commonplace at pools, though
currently, no governmental agency is annually inspecting them. Baseline
data on the number of injuries and drownings associated with public
pools and water attractions is unavailable. Without this information, we
are unable to pinpoint the health and safety risks of these novel
attractions. Our vision is to identify the risks associated with water
attractions, and build a program that is effective in reducing these
risks.

In 2005, the Department of Health purchased a data base system
compatible with local health departments to integrate and enter data on
pools and other environmental health programs. Additionally, the
Department created an advisory committee to address new attractions with
partners who share mutual interests and goals. Language was drafted for
a revision of the pool code to include waterslide regulations and safety
plans, with the intent to create a program effective in reducing unsafe
conditions in recreational water attractions. The proposed draft
revision will go to public hearing and to the legislature in 2006. Our
long-range goal is to gather baseline data, identify risk factors, and
evaluate the new program to determine if revised legislation had a
positive effect in reducing these risk factors.

# INTRODUCTION:

Approximately 200 new and innovative water attractions are designed in
Wisconsin every year. ^3^ Current state regulations do not cover new
complex attractions and data has been difficult to collect to evaluate
trends in injuries and illnesses and at these new attractions. Without
this information, the Department of Health and Family Services (DHFS) is
unable to assess unsafe or unhealthy conditions. Our vision is to define
the risks associated with water attractions, and build a program that is
effective in reducing these risks. The goal is to create a program that
is performance based, focusing on preventative maintenance and standard
operating procedures by operators rather than imposing rigid regulatory
standards.

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

Baseline data on the number of injuries and drownings associated with
public pools and water attractions is unavailable. Additionally, water
quality at these attractions should be evaluated and analyzed to create
a baseline of the overall sanitary condition at pools and attractions.
Without this information we are unable to pinpoint the health and safety
risks of new water attractions. Data is needed to create policies and
develop guidelines on new attractions to ensure the maintenance of
public health and safety.

#######  

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

The number of patrons visiting facilities in search of water recreation
and number of water attractions are increasing. The public perception
remains high and steady, assuming water attractions open to the public
are safe. The funding to manage an expanding program is decreasing. The
number of deaths, injuries and illnesses contributed to unsafe public
pools and water attractions are not known.

![](media/image2.wmf)

####### 

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

The vision and common goal is safe water recreation in public pools and
water attractions, and another governmental agency shares that vision as
well. However, the DHFS became accidental adversaries with the
Department of Commerce (DCOMM) when responsibility for services
(waterslide inspections) were shifted from them, with the expectation
the DHFS would take on the service. DHFS felt unskilled in the task due
to lack of and program planning, which resulted in the goals drifting,
and an inability to provide basic systemic services (i.e. annual
inspections of waterslides). This in turn resulted in a lack of goals
and vision.

The lack of common vision placed the DHFS in a reactionary position,
where at best we can focus only on symptoms, our attention is on
immediate treatment needs, and we only investigate drownings when they
are reported to us. This leads to a lack of measurement and surveillance
of these injuries and drownings. Which correspondingly results in a lack
of identification of injuries and illnesses; usually a drowning or
serious injury is discovered when an attorney calls months later asking
for a copy of the report, which does not exist. The consequence is a
lack of risk and service assessment, and again, and inability to provide
systemic services to the public.

![](media/image3.wmf){width="5.020833333333333in"
height="3.7708333333333335in"}

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

![](media/image4.png){width="3.75in" height="3.8125in"}

Figure 3. Reprinted from CDC's "National Strategy to Revitalize
Environmental Public Health Services" ^4^

## 

This project seeks to fulfill seven of the ten services, and encompasses
all three functions of assessment, policy development, and assurance. Of
the ten services, this project fulfills:

## Monitor environmental health status

The objective of the project is to gather data on injuries, drowning and
illnesses occurring in public pools and water attractions. Additionally,
we aim to collect existing data held by other organizations and agencies
to create baseline data on conditions at the public pools and water
attractions.

## Investigate environmental health hazards in the community

All health hazards that are discovered through monitoring or complaints
are investigated.

Once this data is entered into a universal system, a baseline will be
created, and the data will be evaluated and reviewed for trends.

## 

## Inform and educate people about environmental health issues

Once risk factors are identified and trends are realized, information
will be disseminated to local health authorities, field inspectors,
industry and the general public.

*Mobilize community partnerships*

Partnerships were created with those in the community, non-profit
organizations, industry leaders and local health authorities to
understand the scope of the issue. These collaborations are essential
for policy development.

*Develop policies that support environmental health efforts*

Policies will continue to be created from data that had been gathered
and with support from our partners.

*Enforce laws that protect health and ensure safety*

Policies and Administrative Code requirements are required to be
enforced by environmental health officials. Policies and codes are
dynamic and continue to change.

*Evaluate environmental health services*.

The department audits local agent and regional health departments
including individual inspectors, to determine if the policies are being
followed and to evaluate the effectiveness of the policies in the field.

***National Goals Supported***

CDC Goal: Healthy Travel and Recreation.

Ensure that environments enhance health and prevent illness and injury
during travel and recreation.

And National Strategy Goal II: Support Research -- Objectives:

1\) Define effective approach to address existing and emerging needs

3\) Engaging in community involvement

4\) Encourage innovative environmental public health practices and
services that emphasis prevention

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

Create a program that is effective in reducing the rate of injuries,
illness and drowning occurring in public swimming pools and water
attractions where unsafe or unhealthy conditions exist

[Factors:]{.underline}

Lack of baseline data on the number of injuries, and drownings
associated with public swimming pools and water attractions.

Waterborne illness data not in format conducive for surveillance

Lack of database system to store and retrieve this type of data.

Lack of awareness of pool owners and operators of standards.

Lack of response from owners and operators regarding violations of
standards.

Lack of enforcement system in place to deal with repeat violators.

# 

# [Activities]{.underline}

Purchase effective tool to organize data.

Establish baseline data by completing a baseline sanitary survey of
water attractions.

Obtain injury, illness and mortality records from Vital Statistics
Section associated with public pools.

Obtain injury and illness data from EMS, police officials, insurance
companies and other organizations that gather information on public
pools

Separate drowning and injury data in public pools from all other venues.

Provide education and training for pool operators on safety measures and
waterborne illness prevention.

# [Outputs]{.underline}

Results of the sanitary survey, and number of injuries, illness and
deaths entered into database as baseline data by 1/07.

Ten pool operator-training courses on safety and waterborne illness
prevention will be taught by 7/06.

# [Outcomes]{.underline}

A database will be created capable of capturing data on public pools and
water attractions.

Database will be analyzed to determine if current policies on safety and
illness prevention are consistent with the data complied.

Food Safety and Recreational Licensing Section will have developed a
partnership through data sharing with other sections of the Department
of Health, and open effective communication lines.

Pool operators will have increased awareness and knowledge about how
disease can be spread.

# [Impact]{.underline}

# By December 2007, using our baseline data, we will see 20% reduction of risk factors that contribute to injuries, illnesses, and drowning associated with public swimming pools and water attractions.

# 

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

***Program Goal***: Have a program in place that is effective in
reducing the rate of injuries, illness and drowning occurring in public
swimming pools and water attractions, where unsafe or unhealthy
conditions exist.

***Health Problem***: Injuries, illnesses, and drowning associated with
visits to public swimming pools and water attractions

***Outcome Objective***: By December 2007, critical items causing unsafe
and unhealthy conditions in public swimming pools and water attractions
will be reduced by 20% of the baseline created in 2006.

***Determinant***: Unsafe conditions that result in injuries, illnesses,
and drowning from swimming pools and water attractions

***Impact Objective***: By March 2008, have a program in place that is
effective in recognizing conditions that that lead to illness, injuries
and deaths in swimming pools and water attractions in the state

***Contributing Factors***

1\. Lack of baseline data on violations, injuries and drownings.

2\. Waterborne illness data not in format conducive for surveillance.

3\. Lack of database system to effectively gather and analyze data.

4\. Lack of awareness of pool owners and operators of standards.

5\. Lack of response from owners and operators regarding violations of
standards.

6\. Lack of enforcement system in place to deal with repeat violators.

***Process Objectives***

[Process Objectives]{.underline}:

1.  By March 2006, have a database system in place capable of capturing
    data on public swimming pools and water attractions in the state.

> [Events]{.underline}: Database system purchased in 2005
>
> [Activities]{.underline}: Training on new system commenced in December
> 2005 and will continue throughout 2006 for field staff and office
> personnel

2.  By December 2007, complete a review of data to identify common risk
    factors and trends associated with injuries, illnesses, and
    drownings in public swimming pools and water attractions.

> [Event]{.underline}: Gather and enter all pool information into
> database system
>
> [Activities]{.underline}:

a.  Complete baseline sanitary survey of water attractions

b.  Obtain morbidity records from Vital Statistics Section associated
    with public pools.

c.  Obtain injury and illness data from EMS, police officials, insurance
    companies and other organizations that gather information on public
    pools.

d\. Separate drowning and injury data in public pools from all other
venues

> [Event:]{.underline} Evaluate revised legislation for positive impact
> of reducing risk factors.

# METHODOLOGY:

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

## Monitor Health -Sanitary survey

From 2003-2004, a sanitary survey was initiated and conducted, in
conjunction with the state lab of hygiene, on indoor and outdoor water
parks. This was done to establish baseline water quality data on the
condition of eleven large-scale indoor and outdoor water parks. Pool
waters were sampled and tested quantitatively for seven microorganisms
commonly used in water quality assessment (Enterococci, Total coliforms,
*E coli*, *Pseudomonas aeruginosa*, S*taphylococcus aureus, S.
epidermidis*, Heterotrophic plate count) and other parameters such as
chlorine residual, pH, water temperature and bather load were also
recorded. 94% of the samples were bacteriologically compliant and 88%
were compliant with free chlorine residuals according to the Wisconsin
administrative code requirements for safe pool operation.^5^ However,
low levels of other bacteria were detected, such as pseudomonas and
enterococci, which are not regulated by the administrative code. This
data is now the baseline for water quality in our water parks. Play
features and mat materials used in these novel parks were also sampled
for the seven target organisms, in an effort to determine baseline data
of the abundance of bacteria found in and around the park. Play features
designed for young children were found to contain more bacteria than
adult play features, and materials were evaluated for use in these
settings. The findings demonstrate the importance of understanding the
microbiological implications of these new materials and could
potentially aid state regulators in updating existing regulations to
encompass theming and novel play features found in modern water parks.
This data has been submitted for peer review and publication. ^6^

## Monitor Health- Collaborating with partners

The Bureau of Community Health Promotion collects vital statistical data
from obtained death records. They have provided us with pool drowning
data, both in residential and public settings, from 1999-2004.^7^
Although the actual number of drownings remain constant over the
five-year span, the actual number of drownings may be an underestimate
(Figure 4). It is essential to also review the number of
hospitalizations that occur from near drownings, and the number of
emergency room visits from near drowning (Figure 5). This data is
important because victims may not die immediately from the drowning, but
from complications afterwards, such as pneumonia, and therefore the
actual cause of death would not be recorded on the death certificates as
a drowning.

![](media/image5.wmf){width="4.895833333333333in"
height="2.8333333333333335in"}

Figure 4. Comparison of Hospitalizations and Deaths from Pools in
Wisconsin

The morbidity and mortality of pool related drowning in 2002 is shown in
Figure 5. Unfortunately, the data set is incomplete and this is the only
year we have data for emergency room visits from near drownings. It is
clear with this data emergency room visits should continue to be
monitored and added to the database surveillance.

![](media/image6.wmf){width="4.427083333333333in" height="3.09375in"}

Figure 5. Morbidity and Mortality of Pool Related Drownings in 2002

## Monitor Health- Comprehensive data base system

A comprehensive web-based computer database system was purchased in
summer of 2005, to ensure compatibility between local agent health
departments and regional staff throughout the state. It is designed to
function as a database for a complete environmental health program,
capable of capturing relevant data for all regulated programs. Data will
capture pool types and locations, lifeguard requirements, violations,
accidents, illnesses and outbreaks associated with each facility.
Currently, outbreaks and final reports are recorded within the
Communicable Disease Section but not in any type of database. Basic data
on the outbreaks will be able to be entered into our database for easy
access and could be used for surveillance to observe trends in pool
types. Trial runs of the program show promise though due to the lack of
internet connections available in the northern half of the state, the
web portion needs to be modified to work as software on a laptop. Data
will be downloaded to the main site when a connection is available. By
March of 2006, we hope switch over to this new system to record
inspections.

## Education

Since 2002, over forty presentations have been made at the National
Swimming Pool Foundation's (NSPF) Certified Pool Operator training
courses held in Wisconsin. Pool operators have been informed of the
illnesses and injuries that have occurred over the years in pools and
water attractions. The one-hour presentation also discusses water borne
illness prevention and procedures for clean up of fecal accidents in the
water. CDC recommendations and brochures are explained and distributed.

## Develop policies

The Wisconsin Administrative Code for Safety, Operation and Maintenance
of Public Pools was opened for revision and an advisory committee was
created. This committee consisted of stakeholders including architects,
designers, pool builders, aquatic safety personnel, owners, operators,
lifeguards and local heath inspectors. One primary goal was to review
all new types of water attractions for safety requirements, including
lifeguard and attendant staffing. Each water attraction was voted on by
the committee, and ranked as high, medium or low risk for safety.
High-risk attractions would require a lifeguard, medium would require an
attendant (a person holding no safety certifications, but there to
observe the attraction), and low meant no extra personnel were needed-
safety signage is the only requirement. This task proved to be
difficult. Members had competing interests in this development,
requiring compromises, time management skills, and extensive
negotiations. The results of this collaboration became policy in January
2004 and has been added to the code revision. ^8^

## Create partnerships

The DCOMM and DHFS share a goal for safe water recreation, though in
2003, an accidental adversarial relationship developed when the DCOMM
removed it's authority in an administrative rule to provide annual water
slide inspections, and the DHFS was unable to immediately assume these
responsibilities.

The problem with the old system was that pool owners and operators were
dealing with two regulatory agencies, which caused a great deal of
confusion. Since the DHFS was already in the facility to do pool
licensing and inspections annually, it seemed plausible to take on the
responsibility of inspecting waterslides since the majority of
waterslides empty into a plunge pool. Unfortunately, the DHFS and its
agent health departments did not feel qualified to provide an inspection
of such a structure, and waterslides were left unregulated.

This dilemma was brought to the advisory committee for discussion. A new
concept of a waterslide inspection was created which consisted of
general safety requirements. This inspection would be different than
what was done previously by DCOMM, and it focused on rules, lifeguarding
and attendants, unsafe materials, and added a requirement for a
structural engineer to inspect the facilities once every five years for
bolt degradation and physical stress capabilities. This new type of
inspection was an acceptable compromise for all stakeholders and
resulted in recommended language for the code revision to inspect
waterslides as defined as appurtenances of pools or attractions.

The next step was to get support from agent health departments who
assume inspection responsibilities in their local jurisdictions. The
DHFS attended the Environmental Health section of the Wisconsin
Association of Local Health Departments and Boards quarterly meeting to
present the new inspection concept. The DHFS discussed the urgency of
the decision making process and explained our vision of a waterslide
safety inspection, with the inclusion of a structural inspection by a
third party. This alleviated the local inspectors concern about
performing a task they felt unqualified to do. The vote was unanimous
and the decision to include waterslides in the revision was made with
the support of industry and local health departments. The DCOMM has
continued to work as partners with the DHFS and has agreed to provide
training by their previous waterslide inspectors.

# Next steps:

## Purchase and disseminate data base system

The new system is being distributed to local agent and regional health
departments. Training with field inspectors and local heath departments
on the new program started in December. Training of all field inspectors
on the new system will continue through 2006. Analysis of gathered data
should begin in 2007.

## Inform and Empower

Further work with insurance agencies and the Vital Statistics Section is
needed for complete drowning and injury data that is already gathered,
but not accessible to the department. It is also essential to separate
out drowning data between public pools and other settings. Explaining
our vision and addressing their concerns will hopefully empower the
section to see the need to separate data further for use by our section.
Initiatives from federal agencies who also track drowning data will
encourage collaboration to achieve common goals.

We will continue to provide education and empowerment of pool operators
at NSPF's Certified Pool Operator courses on waterborne illnesses,
injuries, and drownings occurring in Wisconsin's pools.

## Educate and Enforce

A draft revision of the Wisconsin pool code will go to public hearing
and to the legislature for approval in spring 2006. If passed, the
revisions will become law. Training of field staff and industry on the
changes will occur during the summer of 2006 by the DHFS.

State and local inspectors will then enforce the new code, including the
additional safety requirements for water attractions and annual safety
inspection of waterslides.

## Evaluation

Evaluation and Training Officers will evaluate the application of the
new code by local health departments and inspectors by verifying
competent workforce and consistent enforcement of state regulations.
They will provide feedback and retraining as needed.

A standardization process is being developed for pool inspectors to
promote uniformity in citing provisions of the pool code. This would
include focusing on interventions and risk factors and applying a
performance based inspectional approach to pool and water attraction
inspections. Field standardization would be conducted with inspectors
who have already received basic training. Through this procedure,
inspectors will demonstrate knowledge in the understanding and
interpretation of the pool code; waterborne illness and injury risk
factors, proper use of test kits and exhibit the necessary communication
skills to conduct a thorough pool and water parks inspection.

# 

# Expected Outcomes:

## Assurance

Since public perception is based on the assumption that all open water
attractions are safe, the code changes are expected to pass because it
ensures the public's safety where indeed one is lacking (currently there
are no operation requirements for waterslides, though industry ensures
safety with in-house evaluations and inspections). Accidents will always
happen and sometimes cannot be prevented, but through evaluation of the
revised legislation, we hope to see the number of risk factors that
cause unsafe or unhealthy conditions to be reduced by the baseline
created in 2006.

Unnecessary risks will be avoided with heightened owner and operator
knowledge from the training courses provided by the DHFS.

Local health departments will increase their knowledge and
responsibility on hiring competent staff because they will be audited
for compliance with state policies and laws. These evaluations will
verify policies and laws are enforced consistently, and incentives and
consequences will be created by the DHFS to promote responsibility, to
ensure safety throughout the state.

Industry, designers and owners will create their own safety plans for
lifeguarding and use risk analysis for new attractions of all sorts.
Water attractions will be evaluated using a performance-based standard,
combining scientific evidence for regulations and requirements.

# 

# 

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

I am thankful for the opportunity to meet and work with such outstanding
individuals in the EPHLI and the CDC. Networking with professionals and
colleagues from other states gave insight about the commonality we face
working in public health. EPHLI was beneficial in providing tools to
self-understanding, while concentrating on the big picture.
Understanding my personal communication and social style allowed me to
focus on strengthening my weaknesses. Using systems thinking illustrated
how situations continue to exist and alerted me to objections and
limiting processes that affect a current system. Learning how systems
work assisted me to develop appropriate interventions for problem
solving. I believe the relationships created this year will be a
foundation for future collaborations, and I am fortunate to be a part.
EPHLI has proved to be an invaluable experience for me, and I hope many
others will be afforded the same opportunity.

# ABOUT THE EPHLI FELLOW

Tracynda's interest in environmental health began while she was
completing her undergraduate degree at University of
Wisconsin-Milwaukee, when the city was faced with the largest waterborne
outbreak in the U.S. She became fascinated on how a microorganism not
well understood, crippled the city she lived in. She attended the
University of South Florida, College of Public Health to study under
renowned water pollution microbiologist, Dr. Joan Rose. She competed
research on the viability of C*ryptosporidium parvum* in marine waters
and received a master's degree in public health. From there, she moved
to California to supervise the microbiology department in an
environmental laboratory until she realized her interest lied working
directly with the public. She moved back to Wisconsin and joined a local
health department as an environmental health specialist, enforcing local
and state public health laws and regulations. Currently, she is a
program manager in the Wisconsin Division of Public Health where her
oversight includes food safety, swimming pools and water attractions.
She writes policies and procedures, trains and evaluates local and
regional health departments, and has conducted extensive research on the
sanitation condition of both indoor and outdoor waterparks. She has been
actively involved in revising and updating antiquated health codes for
both the design and construction and safety health and maintenance of
public pools. Recently, her initiative to provide diaper-changing
stations in all pool areas was passed by the Wisconsin legislature in
January 2005, requiring both sex restrooms to provide this necessary
amenity in an effort to reduce transmission of waterborne diseases.

# REFERENCES

1\. Wisconsin Department of Health and Family Services, Food Safety and
Recreational Licensing Section.

2\. R. Snyder, Wisconsin Dells Tourist Bureau Director, personal
communication.

3\. L. Docken, Department of Commerce, personal communication.

4\. Public Health Functions Steering Committee.
http://www.apha.org/ppp/science/10ES.htm.

5\. Wisconsin Administrative Code. Chapter HFS 172. Safety, maintenance
and operation of public swimming pools. Register May 2002, No. 557

6\. Davis, T., J. Standridge, and A. Degnan. " Bacteriological Analyses
of Indoor and Outdoor Water Parks in Wisconsin." Submitted to Envir.
Hlth Perspectives, 2006.

7\. Wisconsin Interactive Statistics on Health.
http://dhfs.wisconsin.gov/wish/

8\. Wisconsin Department of Health and Family Services. "Lifeguard
Policy", January 23, 2004.