H.e.a.t. Toronto - Recreational Water Presentation

1. H.E.A.T

2. Recreational Water
and
Public Health
Mahesh
Patel
MSc.,
CPHI(C)
April
21,
2016

3. Presentation Content
 Recrea<onal
Water
and
Public
Health
• Diseases,
Injury
and
Death
• The
Common
Goal

Overview
of
Public
Health
in
Ontario
• Legisla<ve
Structure

TPH’s
Recrea<onal
Water
Program
• Disclosure
of
Inspec<on
Outcome
–
Why?
• Overview
of
SwimSafe
Disclosure
Program

Provincial
renewal
of
HPPA
regula<ons
–
Update

4. Recreational Water and Public Health

Recrea<onal
water
related
ac<vi<es
–
excellent
source
of
health,
fitness,
enjoyment
and
good
health
• But
inherently
hazardous
• Can
cause
diseases,
injury
and
death
 Hotel
industry
–
an
important
public
health
partner
in
• Promo<ng
health
and
fitness
• Preven<ng
illness
• Preven<ng
injury
and
death

5. Recreational Waterborne
Diseases
Pathogen
Type
Organism
Infec5ve
dose
Mode
of
infec5on
Disease
Symptoms
Bacterial
Legionella
107
cells
Inhala<on
of
aerosolized
contaminated
water
Legionellosis
fa<gue,
fever,
headache,
muscle
and/or
abdominal
pain,
jaundice
and
mental
confusion
pneumophila
Legionnaire's
disease
Can
be
fatal
Pon3ac
fever
rela<vely
mild,
influenza-­‐like
illness
Source:
h]p://www.dgmag.it/altro/salute-­‐benessere/salute/legionella-­‐
sintomi-­‐cure-­‐prevenzione-­‐98267

6. Pseudomonas
direct
body
contact
with
waters
containing
sufficient
Ear
and
eye
infec<ons
itchy
and
painful
aeruginosa
quan<<es
of
the
organism
Folliculi<s
(inflamma<on
of
the
hair
follicles
of
the
skin)
discharges
of
pus
Derma<<s
present
as
a
red,
itchy
rash
Staphylococcus
direct
contact
with
skin
(cuts
and
scratches),
ear,
eye
boils,
pustules,
derma<<s,
pus
forming
infec<ons
aureus
folliculi<s
and
impe<go
pedis
contact
with
infected
skin
scales
Pathogen
Type
Organism
Infec5ve
dose
Mode
of
infec5on
Disease
Symptoms
Source:
h]p://microbiologyglossary.wikispaces.com/Pseudomonas
+fluorescens

7. Recreational Waterborne
Diseases
Pathogen
Type
Organism
Infec5ve
dose
Mode
of
infec5on
Disease
Symptoms
Protozoan
Parasites
Giardia
50
cysts
accidental
inges<on
of
contaminated
waters
Giardiasis
explosive,
watery
diarrhea,
nausea
lamblia,
intes3nalis
intes<nal
upset,
fa<gue,
low-­‐
grade
fever
and
chills
Cryptosporidium
80
to
140
oocysts
accidental
inges<on
of
contaminated
waters
Cryptosporidiosis
profuse,
watery
and
some<mes
mucoid
diarrhea
hominis,
parvum
nausea,
vomi<ng,
abdominal
pain,
weight
loss,
anorexia
and
low-­‐grade
fever

8. Fungal
Tinea
contact
with
fungi
in
damp
areas
(e.g.
showers,
locker
rooms,
swimming
pools)
Athlete’s
foot
skin
fissures
or
scales
that
can
be
red
and
itchy
pedis
contact
with
infected
skin
scales
Pathogen
Type
Organism
Infec5ve
dose
Mode
of
infec5on
Disease
Symptoms
Recreational Waterborne Diseases

9. Routes of infection
Route
of
Infec5on
Infec5ng
Pathogen
 Swallowing
pool
water
 Skin
contact
with
pool
water
causing
bacterial
infec<on
 Pool
water
inhala<on
 Skin
contact
with
pool
water
causing
fungal
infec<ons
 Cryptosporidium,
Giardia
 Pseudomonas
aeruginosa,
(folliculi<s,
ear
and
eye
infec<on),
 Legionella
pneumophila
 Tinea
pedis,
Trichophyton

10. Outbreaks Associated with Recreational
Water
• US
reported
90
Recrea<onal
water-­‐
associated
outbreaks
• 1,788
cases
• 95
(5%)
hospitaliza<ons,
and
• one
death
Source:
CDC
From
:
h]p://www.cdc.gov/mmwr/preview/mmwrhtml/mm6424a4.htm#Tab

11. Pool & Spa - Injuries

12. Pool & Spa - Injuries

13. The
Abigail
Taylor
Story
 On June 29, 2007 six years old Abigail Taylor
accidentally fell onto an open drain on her buttocks
 The suction forcefully dislodged and removed a large
section of her small intestine through her anus
 Abigail lost 6.5 meters (21 feet) of her small intestine in
the accident
 She received a triple organ transplant to replace her
small intestine, liver and pancreas due of the accident
 Abigail suffered transplant-related cancer, she could
not eat or drink and died nine months latter
Pool & Spa - Injuries

14. The
Cause
of
Abigail’s
Accident
 Negligence – Failure to secure the
drain cover despite awareness of
the problem
 Financial cost savings at the
expense of health & safety
 Weak or lacking regulation
 Inadequately trained staff
Pool & Spa - Injuries

15. Public Pools & Spas – Same Goal
• Maximize
enjoyment
without
compromising
Health
and
Safety
of
patrons
• Preven<on
of

Deaths

Waterborne
diseases

Injuries
&
accidents
• Maintain
clean
and
safe
facili<es
• Compliance
with
minimum
standards
(regula<on)
Regula5ons
(565
&
428)
&
Guidelines
(wading
pools)
Owners/
Operators
&
Lifeguards
Health
Units
/
PHIs

16. Public Health in Ontario - Background
• Public
Health
–
Provincial
Jurisdic<on
• Health
Protec<on
and
Promo<on
Act
• Ontario
Public
Health
Standards
and
Protocols
–
establish
the
minimum
requirements
for
fundamental
public
health
programs
and
services
• 36
Health
Units
deliver
Public
Health
programs
and
services
as
set
out
under
the
Health
Protec<on
and
Promo<on
Act

17. Legislative Structure
•
Legislative Mandate for Ontario's Boards of Health
• Powers of the Medical Officer of Health (MOH)
• Orders and appeals
• Rights of Entry
• Powers of inspection
• Enables the Ontario Ministry of Health to make regulations
• Enforcement – sets out offences
Ontario’s
Health
Protec5on
and
Promo5on
Act
(HPPA)

18. TPH’s Recreational Water Inspection
Program
• 35
Health
Hazard
focus
PHI’s
• Duty
to
enforce
HPPA
regula<ons
and
prevent
Health
Hazards
• Over
1700
regulated
and
non-­‐regulated
facili<es
to
inspect

19. Recreational Water in Toronto

20. • Mandated
Inspec<on
Frequencies:
• Indoor
Public
Pools
&
Spas
(Hot
Tubs)
=
4
X
year
• Outdoor
Public
Pools
&
Spas
=
2
X
per
season
• Non
regulated
Wading
pools,
Splash
and
Spray
pads
=
1
X
year
• Over
5000
inspec<ons
and
re-­‐inspec<ons
conducted
in
2015
• Closures
and
charges
TPH’s Recreational Water Inspection
Program

21. Percentage Non-Compliance
Year Closed Re-inspection D-Noted Satisfactory Non Comp
2010 3.8 3.5 48.2 44.6 55.40
2011 4.6 4.8 51.0 39.6 60.43
2012 4.2 3.5 54.1 38.2 61.76
2013 3.6 4.7 57.0 34.7 65.32
2014 5.3 7.0 57.1 30.6 69.41
MEAN 4.3 4.7 53.5 37.5 62.46

22. Public Disclosure – Dine Safe
Experience
• Compliance
with
Food
Premises
Regula<on

before
public
disclosure
–
approximately
50%

one
year
aoer
implementa<on
of
disclosure
–
78%

today
–
92%
• Enforcement
of
the
FP
Regula<on

increased
significantly
since
introduc<on
of
public
disclosure
 decreased
steadily
as
compliance
increased

today
some
enforcement
s<ll
necessary
• Empowered
the
public
• Owners/operators
are
also
be]er
informed

23. Following the path of Dine Safe -
SwimSafe

24. Following the path of Dine Safe -
SwimSafe
• Inspec<on
administra<on
processes
have
been
overhauled

new
pool
and
spa
forms

revised
policy
and
procedures

ac<on
algorithms
-­‐
controlled
and
consistent
• Signage
by-­‐law
approved
by
B.o.H
and
City
Council
• Full
Implementa<on
of
SwimSafe
Disclosure
system
completed

inspec<on
forms
 operator
educa<on
period
 pos<ng
of
disclosure
signs
 enforcement
now
underway

25. SwimSafe
Disclosure System

26. SwimSafe – Disclosure System
• September
2011
-­‐
Disclosure
System
Requiring
Pos<ng
of
Inspec<on
No<ces
was
adopted
by
B.O.H
• May
2015
-­‐
Municipal
Code
Chapter
520
(Pos<ng
of
Inspec<on
No<ces)
was
adopted
by
Toronto
City
Council
• October
2015
-­‐
Public
Health
Inspectors
started
issuing
Inspec<on
No<ces
• January
2016
–
Public
Health
Inspectors
started
ensuring
Municipal
Code
520
is
complied
with
(i.e.
PASS,
CONDITIONAL
PASS,
CLOSED
signs
are
posted
as
per
Municipal
Code
520)

27. SwimSafe
Inspector’s Field
Guide

Designed
to
 Minimise
variance
 Consistent
correc<ve
ac<on
 9
Inspec<on
sec<ons
e.g.
Water
Quality
and
Chemistry
Recircula<on
and
mechanical
systems

3
Risk
Categories
e.g.
Crucial,
Significant
and
Minor

28. SwimSafe
New Inspection
Forms
3
Sec5ons
Facility
Informa<on
Inspec<on
Findings
Outcome

29. New Inspection
Forms

30. PASS
Inspection Notice
 Issued
when
the
pool/spa
is
in
compliance
with
the
regula<ons
 Minor
viola<ons
that
have
no
significant
public
health
&
safety
impact
 Sign/s
must
be
posted
in
a
conspicuous
loca<on
 Before
entrance
to
the
pool/spa
enclosure
 Signs
can
not
be
obscured
and/or
altered
in
anyway

31. CONDITIONAL PASS
Inspection Notice
 Issued
when
the
pool/spa
is
NOT
in
compliance
with
the
regula<on
and
includes
infrac<ons
that
 Are
likely
to
have
health
and
safety
impact
 May
become
an
imminent
health
and
safety
hazard
if
not
mi<gated
in
a
<mely
manner
 Infrac<ons
must
be
corrected
within
24
to
48
hours
 May
result
in
CLOSURE
if
not
corrected
 Sign/s
must
be
posted
in
a
conspicuous
loca<on
 Before
entrance
to
the
pool/spa
enclosure
 Signs
can
not
be
obscured
and/or
altered
in
anyway

32. CLOSED
Inspection Notice
 Issued
when
an
imminent
health
hazard
exists
and
may
result
in
 Serious
injury
or
 Death
 Issued
in
conjunc<on
with
an
HPPA
sec<on
13
health
hazard
(Closure)
order
 Pool/Spa
must
remain
closed
 Pool/Spa
may
only
open
aoer
a
re-­‐inspec<on
by
a
PHI
 Sign/s
must
be
posted
in
a
conspicuous
loca<on
 Before
entrance
to
the
pool/spa
enclosure
 Signs
can
not
be
obscured
and/or
altered
in
anyway

33. Guidance and Education

34. SwimSafe - Enforcement

35. SwimSafe – Disclosure System
WEB
hQp://www.toronto.ca/health/swimsafe/

36. SwimSafe – Disclosure System
WEB

37. SwimSafe – Disclosure
System WEB
 Legend
 Name
Address,
Loca<on
and
Type
of
Facility
 Last
Inspec<on
date
&
History
 Search
Func<on

38. Digital Water Chemistry Tests
• Uses
photometer
to
calculate
results
• Improved
accuracy
• Accuracy
is
verifiable
against
standard
solu<ons
• Robust
–
solid
reagents
are
stable
and
reliable
in
hot
and
cold
condi<ons
• Eliminates
interference
• Calibra<on
not
required

39. Changing Regulations

40. 40
The Ministry of Health and Long-Term Care (MOHLTC) is undertaking a comprehensive
review to inform the modernization of regulations made under the Health Protection and
Promotion Act (HPPA) that govern food and water safety in Ontario.
ISSUE
• Food and water safety in Ontario is currently governed by six regulations under the
HPPA:
• Stakeholders have identified issues that can strengthen our current regulatory
framework.
• Changes in technology and evidence present an opportunity to modernize our
regulations, ensuring they are responsive and adaptive.
Regulation Year Introduced
Ontario Regulation 319/08 – Small Drinking Water Systems1 2008
Ontario Regulation 562 – Food Premises 1967
Ontario Regulation 565 – Public Pools 1944
Ontario Regulation 428/05 – Public Spas 2005
Ontario Regulation 568 – Recreational Camps* 1940
Ontario Regulation 554 – Camps in Unorganized Territory*
*Includes requirements for both food safety and water supply
1944
CONTEXT FOR ACTION
1 The Small Drinking Water Systems transitional and permanent regulations were introduced in 2008 and do not
warrant review at this time; however, the transitional regulation, Ontario Regulation 318/08, is due to be repealed.

41. 41
REGULATORY REVIEW
Guiding Principles:
A flexible and responsive regulatory
framework that is evidence-based
and supports innovation
Comprehensive regulations that set
clear expectations for regulated
parties
Ensure public health benefit is the
overarching consideration;
streamlined, concise and user-
friendly
Optimal use of alternative
approaches (i.e., outcomes-based
or non-regulatory approaches)
Changing Regulations

42. 42
Communicate plan to
Stakeholders
Industry; Public Health
Units and Associations;
Federal, Provincial and
Municipal Stakeholders
Stakeholder
Consultation
Posting of Draft
Regulations on
Regulatory
Registry
(minimum 45
days)
4 Working Groups:
a. Food Premises
b. Public Pools & Spas
c. Camps (Rec & Unorg’d Territ’rs)
Comprised of Public Health
Associations and Public Health
Unit representatives
4 Focus Groups:
Industry Perspectives
STAKEHOLDER ENGAGEMENT SCHEDULE
Regulations
in force
(anticipated):
2017
Nov-Dec 2015 Jan-Jun 2016 Late 2016 / Early 2017

43. Thank You!