Frequently Asked Questions about the Model Aquatic Health Code (MAHC)

1. What is the MAHC?
2. Why is the MAHC needed?
3. What are the anticipated health outcomes?
4. When will the complete MAHC be available?
5. Who wrote the MAHC?
6. Has there been an opportunity for public comment?
7. What is the scientific basis for the MAHC provisions?
8. How can the MAHC help prevent cryptosporidiosis (“Crypto”) outbreaks like the one in Utah in 2007?
9. How does the MAHC relate to model codes developed by industry?
10. How does the MAHC differ from the Virginia Graeme Baker Pool and Spa Safety Act (VGB)?
11. What if I have concerns about the MAHC's effect on business?
12. How will the MAHC affect the construction and operation of pools in my area?
13. What are the roles for federal, state, and local government agencies with regard to aquatic health?
14. What are the gaps in current state aquatic health codes?
15. What if my jurisdiction’s regulations are stricter than the MAHC?
16. Does my jurisdiction need to use all modules in the MAHC?
17. If facilities in my jurisdiction don’t have high incidence of illness or injury, do we still need to review and update our aquatic health code?
18. Is implementation of a provision necessary if it is graded as a “C”?
19. What other resources are available?
20. Where can I get more information and assistance?

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1. What is the MAHC?

The Model Aquatic Health Code (MAHC) is a resource for local and state agencies and others interested in adopting or revising public health laws related to preventing illness and injury associated with treated water recreational swimming venues such as pools, hot tubs/spas, and interactive fountains.

The MAHC provides sample guidelines and wording for design, construction, operation, maintenance, and management standards (note that guidelines for facility design and construction pertain to new construction and major renovations only, not existing aquatic facilities). These guidelines are divided into fourteen modules. Modules can be used individually or as a comprehensive set. Each module is accompanied by an annex summarizing the scientific evidence base, research and other materials used to inform the MAHC provisions.

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2. Why is the MAHC needed?

Since 1978, the number of illness outbreaks associated with recreational water has increased significantly. Many of these illnesses can be prevented by proper maintenance and water treatment and by updated disease prevention practices (for example, supplemental treatment of water with ozone or ultraviolet light).

In the United States, there is no federal regulatory agency responsible for aquatic facilities. State and/or local public health officials develop, review, and approve all pool codes governing the design, construction, operation, and maintenance of swimming pools and other aquatic facilities. Therefore, requirements for preventing and responding to recreational water illnesses, injuries, and drowning can vary significantly among local and state agencies. In addition, maintaining and updating requirements to reflect the latest science requires a great deal of time and resources.

In 2005, CDC sponsored a workshop—Recreational Water Illness Prevention at Disinfected Swimming Venues—to discuss ways to minimize recreational water illnesses spread through disinfected swimming venues. The workshop brought together experts from different disciplines working in state, local, and federal public health agencies, the aquatics industry, and academia. A key recommendation from the group was to develop a model aquatic health code that local and state agencies could use as a guide for science-based practices to promote healthy swimming. The group suggested the code be free, accessible, evidence-based, and updated on a regular basis. The group also suggested that in addition to waterborne diseases, the code should address drowning, chemical injuries, and other public health concerns associated with recreational water. The following is a summary of key public health issues affected by the design, construction, operation, and maintenance of pools and other aquatic facilities:

• Outbreaks of waterborne diseases. Waterborne diseases include gastrointestinal, skin, ear, respiratory, eye, neurologic, and wound infections or irritation resulting from exposure to microbial or chemically-contaminated swimming water. These illnesses can pose serious and life-threatening risk to the very young, the elderly, pregnant women, and those with weakened immune function. Waterborne disease outbreaks associated with recreational water have increased significantly over the past several decades.
• Injuries and deaths from drowning. Drowning is the leading cause of injury death for children 1-4 years of age. Among children under 4 years, half (50.1%) of fatal drowning incidents and a majority (64.6%) of nonfatal drowning incidents occur in swimming pools.
• Emergency room visits. More than 30,000 children under the age of 10 visit the emergency room for swimming-related issues each year. From 1998-2007, injuries associated with pool chemicals accounted for more than 4,000 emergency room visits each year.

3. What are the anticipated health outcomes?

Use of the MAHC may help reduce the risk of diseases and injuries and promote healthy and safe swimming.

We hope the practices promoted in the MAHC will lead to the following system improvements:

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

By adopting the practices outlined in MAHC provisions, jurisdictions can reduce the likelihood of adverse health outcomes in their jurisdiction, including reduced risk of the following long-term health outcomes:

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

4. When will the complete MAHC be available?

All MAHC modules will be posted for the first public comment period in the first few months of 2013. We hope to have all modules combined into a single document and available for the second public comment period by summer 2013. Then we will incorporate comments on the combined MAHC and release the final first edition by the end of 2013.

Learn more about the public comment process.

5. Who wrote the MAHC?

The MAHC is a collaborative effort among the Centers for Disease Control and Prevention and more than 130 volunteers from across the United States with expertise in aquatic venues, health, or safety. These experts include federal, state and local public health officials; researchers; and representatives of the aquatics industry, certification organizations, and not-for-profit aquatic associations.

To learn more about these experts, see the complete list of MAHC Steering Committee and Technical Committee members.

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6. Has there been an opportunity for public comment?

Yes. Ensuring multiple opportunities for public comment has been a priority from the beginning. Each module was developed by the appropriate Technical Committee, approved by the MAHC Steering Committee, and posted for public comment for 60 days. After the 60-day public comment period, the Steering Committee and appropriate Technical Committee(s) reviewed the comments and revised the modules as needed. Sometimes they posted revised interim modules.

After all of the modules are revised, we will post the complete MAHC for an additional 60-day public comment period to allow stakeholders to review sections across modules and check the entire MAHC for completeness. In addition to the formal public comment periods included in the MAHC development process, there may be additional opportunities for public comment at the state or local level as jurisdictions consider adopting the MAHC.

Learn more about the public comment process.

7. What is the scientific basis for the MAHC provisions?

Each MAHC module is accompanied by an annex that provides further information about the content of the corresponding module and the scientific rationale for the standards suggested in the code.

The annexes:

• Give explanations, scientific data, and references to support why specific recommendations are made;
• Discuss the rationale for making decisions about code content;
• Provide a discussion of the scientific basis for selecting certain criteria;
• Explain why other scientific data might not have been selected (for example, inconsistencies in data);
• Highlight areas where additional research may be needed;
• Discuss and explain the terminology used; or
• Provide additional information, including summaries of scientific studies, charts, graphs, or other reference materials.

Read the modules and annexes.

8. How can the MAHC help prevent cryptosporidiosis (“Crypto”) outbreaks like the one in Utah in 2007?

Cryptosporidium is a microscopic parasite that causes the diarrheal disease cryptosporidiosis. Both the parasite and the disease are commonly known as "Crypto." Outbreak investigations routinely show that many people continue to swim despite having a diarrheal illness. This is likely the cause of a massive outbreak of cryptosporidiosis that affected thousands of people and over 450 swimming venues in Utah in 2007. In 2007-2008, Crypto caused at least 58 outbreaks of diarrheal disease associated with recreational water, resulting in at least 12,137 cases of illness. As a chlorine-tolerant parasite, Crypto can survive for days in even a well-chlorinated pool. The MAHC can help prevent Crypto outbreaks by highlighting evidence-based practices that can reduce the risk of disease spread. The MAHC recommends additional secondary disinfection safeguards such as the use of ultraviolet light or ozone, which kills Crypto, particularly for increased-risk aquatic venues like wading pools.

9. How does the MAHC relate to model codes developed by industry?

The MAHC is a free, open-access resource developed to help jurisdictions ensure that their aquatic codes are based on the latest and most scientifically sound data available. The MAHC complements building-specific codes, such as the Uniform Swimming Pool, Spa and Hot Tub Code (USPSHTC) developed by the International Association of Plumbing and Mechanical Officials (IAPMO) and the International Swimming Pool and Spa Code (ISPSC) developed by the International Code Council (ICC).

To ensure that the various pool codes are complementary, CDC has signed agreements with both ICC and IAPMO. We paid careful attention to omit conflicts and avoid overlap between the MAHC and building codes. The MAHC primarily addresses issues for which environmental public health officials have principal regulatory responsibility, including most aspects of management and operations. Codes like the USPSHTC and the ISPSC are intended primarily to address issues over which building code officials have principal regulatory responsibility, including most structural, mechanical, and electrical components.

In addition, the MAHC primarily addresses public pools and aquatic venues, whereas other codes may apply to residential pools. There is inherent overlap between some of these areas. For public health issues where the MAHC guidelines are more stringent than those in the USPSHTC or the ISPSC, we encourage jurisdictions to consider the scientific evidence in the MAHC annexes as well as their local conditions to determine the most appropriate regulations for their communities.

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10. How does the MAHC differ from the Virginia Graeme Baker Pool and Spa Safety Act (VGB)?

The Virginia Graeme Baker Pool and Spa Safety Act (VGB) is a federal law passed in 2008 that requires public pools and spas to use unblockable drain covers or other specified devices or systems designed to prevent suction entrapment. (Entrapment can occur when a body part or an object worn by the swimmer, such as jewelry, becomes entangled or stuck in the suction outlet cover, or when a body part forms a seal and suctions the swimmer to the outlet cover.)

There are several differences between the MAHC and VGB. While the VGB is a federal law requiring compliance, the MAHC is not a federal law and carries no regulatory authority unless adopted, in whole or part, by a state or locality. Rather, the MAHC is a resource that state and local agencies can use to update their own codes. The MAHC was created through a collaborative effort among public health and the aquatics sector, with opportunities for public review and comments. VGB targeted all pools; the MAHC design and construction elements pertain to new construction only (and only in those jurisdictions that adopt the MAHC). Finally, VGB only relates to unblockable drain covers. The MAHC covers a range of public health concerns, including waterborne disease, drowning and other injuries, and chemical exposure.

11. What if I have concerns about the MAHC's effect on business?

The MAHC is not a federal law, so it will primarily affect aquatics businesses operating in jurisdictions that choose to adopt all or parts of the MAHC. For larger aquatics industries operating facilities in multiple localities or states, the MAHC could lead to more consistent design, construction, operation, and maintenance of pool and other aquatic facilities.

By incorporating the MAHC standards, aquatics facilities can reduce the risk of outbreaks of waterborne disease, drowning, and chemical injuries at their facilities. It is important to note that many MAHC provisions, particularly those related to design and construction, pertain to new construction only or to major renovation and will not require retrofitting of existing pools.

The aquatics sector is involved in the MAHC Steering Committee and Technical Committees alongside public health experts. This helps ensure that the standards proposed by the MAHC drive meaningful change while reflecting practical realities. We hope that the design, maintenance, and operation of aquatic facilities become increasingly science-based through gradual changes that allow all parties to prepare. We share the aquatics industry’s goal of making swimming healthy and safe.

Anyone can submit public comments.

12. How will the MAHC affect the construction and operation of pools in my area?

The MAHC is intended to provide optional language to make the construction and operation of pools safer and healthier. States and localities that choose to adopt the MAHC may affect pool operations by incorporating science-based practices into pool operation and maintenance.

MAHC provisions relating to design and construction will pertain primarily to the construction of new pools and will not require retrofitting of existing pools. Over time, the MAHC standards could drive greater consistency in pool construction and operation requirements.

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13. What are the roles for federal, state, and local government agencies with regard to aquatic health?

In the United States, there is no federal regulatory authority responsible for design, construction, operation, and maintenance of aquatic facilities. State and/or local legislatures or agencies develop, review, and approve all pool codes. These codes are implemented by state and/or local public health officials and, in some cases, building code officials.

As a federal agency, CDC tracks illnesses and injuries associated with recreational water nationally through reports it receives from state and local partners. When state and local public health agencies detect an outbreak associated with treated recreational water, they might ask CDC to investigate or help control the outbreaks. Data collected during outbreak investigations and through research are then used to inform CDC recommendations and policy decisions taken by state and local regulators.

14. What are the gaps in current state aquatic health codes?

Each jurisdiction’s aquatic health code is different and will have to be evaluated by stakeholders in that jurisdiction. However, the abstract for each module of the MAHC provides a short overview of the key components that the MAHC drafters thought were most important in that module.

For example, the Hygiene Facilities module is intended to help improve swimmer hygiene to reduce the risk of health effects associated with poor water quality. Thus, the module contains sample requirements for new or modified construction that include the following:

• Minimum distances for hygiene facilities from aquatic venues.
• Criteria for diaper-changing stations.
• Implementation of rinse showers versus cleansing showers.

Read the abstracts for highlights from each module.

15. What if my jurisdiction’s regulations are stricter than the MAHC?

The MAHC is not a federal law and is only enforceable once adopted by a particular state or locality. The MAHC provides guidance on minimum standards for the design, construction, operation, maintenance, and management of aquatic venues needed to protect public health and safety.

State or local stakeholders should evaluate the current laws and practical considerations in their jurisdictions to determine the most appropriate use of the MAHC in their communities. Jurisdictions may choose not to adopt the MAHC at all or may choose to adopt or revise all or parts of it to meet their needs.

16. Does my jurisdiction need to use all modules in the MAHC?

No. Each module addresses a different aspect of aquatic health and safety. These aspects include contamination response, operator training, risk management, ventilation and air quality, regulatory program administration, facility design, and others.

Stakeholders should evaluate current laws and practical considerations in their jurisdictions to determine the most appropriate use of the MAHC in their community. Jurisdictions may choose not to adopt the MAHC at all, or may choose to revise all or parts of the MAHC to meet their needs before adopting as regulation.

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17. If facilities in my jurisdiction don’t have high incidence of illness or injury, do we still need to review and update our aquatic health code?

Low incidence of recreational water illness and injury in a jurisdiction does not mean that aquatic venues in that jurisdiction are optimally preventing and controlling the risk of recreational water illness and injury. Jurisdictions should also consider the recent increase in outbreaks of Cryptosporidium, which is not effectively controlled by traditional chlorination practices, as they review their aquatic health codes.

The MAHC modules are based on the best scientific data available for protection of public health. These guidelines are based on the principle of reasonable risk reduction, meaning that they are intended to minimize opportunities for recreational water illness and injury. As is the case with many public health prevention efforts, the value is often more easily understood after a tragedy occurs, such as a drowning, chemical poisoning, or outbreak. By incorporating evidence-based practices based on the science, jurisdictions reduce the likelihood of these events occurring in their communities.

18. Is implementation of a provision necessary if it is graded as a “C”?

Jurisdictions are welcome to adopt all or parts of the MAHC based on their needs. The purpose of the MAHC grading system is to show the strength of scientific support for MAHC provisions and to identify areas where more research is needed.

In the grading system of the MAHC,

• An “A” grade means that the recommended practice is supported by scientific data.
• A “B” grade means that the recommended practice is generally accepted by public health officials, aquatics industry representatives, public health researchers, and other stakeholders, but specific scientific data for that practice are not yet available.
• A “C” grade means that scientific data on this issue are not available and there is no consensus about the best practice. Sections graded “C” were drafted using the best judgment of the experts on the relevant technical committees.

The ultimate goal is to increase the scientific underpinning for MAHC by driving aquatics-related research in key areas. Thus, over time, we hope that more and more practices will be raised to “A.”

19. What other resources are available?

• The MAHC website.
• MAHC presentations and webinars.
• Data about the burden of illnesses and injuries relevant to the MAHC.
• Materials with information about recreational water illnesses (for public health officials, aquatics staff, and the public).
• Information about recreational water injuries.

20. Where can I get more information and assistance?

For questions or comments about the Model Aquatic Health Code, please email MAHC@cdc.gov.

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