Pool Chemical–associated Injuries in

Public and Residential Settings—

United States, 2003–2012Michele C. Hlavsa, RN, MPH

Sarah A. Collier, MPH

Michael J. Beach, PhD

6th International Swimming Pool & Spa Conference

March 17–20, 2015

National Center for Emerging and Zoonotic Infectious Diseases

Healthy Swimming Program

Pool Chemical—associated Health EventIndianapolis, 2012*

� Chlorine and acid likely

mixed and generated toxic

chlorine gas due equipment

failure and/or operator

error

� ~200 patrons and staff

members affected

� ~70 taken to hospital

� >5 admitted

* Source: Indianapolis Star, June 21, 2012.

Reports of Pool Chemical—associated Health Events

� Case reports

• Fisher AA. Clin Dermatol 1987;5(3):36–40.

• Shippert BW. Ann Emerg Med 2010;55(4):370–2.

� Series reports

• Thomas HL, Murray V. J Public Health 2008;

30(4):391–7.

• CDC. MMWR 2009;58(18);489–93.

• CDC. MMWR 2011;60(39);1343–7.

• Hlavsa MC et al. MMWR 2014;63(19);427–30.

• Anderson AR et al. J Environ Health 2014;

76(9):10–5.

National Electronic Injury Surveillance System(NEISS)

� Captures data on emergency department (ED)* visits

for injuries associated with consumer products

* US term “emergency department (ED)” same as UK term “accident and emergency (A&E)”.

NEISS Data Fields for Each Report

� Product code(s), where pool chemical code=938

� Incident location

� Patient disposition

� Most severe diagnosis

� Most seriously injured body part

� Patient

• Age

• Sex

• Race/ethnicity

� Narrative

NEISS

� Captures data on ED visits for injuries associated

with consumer products

NEISS

� Captures data on ED visits for injuries associated

with consumer products

� Collects injury data from a nationally representative

probability sample of ~100 hospitals across the

United States

• Weigh each case based on inverse probability of

hospital being selected

– Calculate national estimate and

95% confidence interval (CI)

– Calculate rate per 100,000 person-years using

U.S. Census population estimates** Source: www.census.gov/popest/data

0

1,000

2,000

3,000

4,000

5,000

6,000

2003 2005 2007 2009 2011

Na

tio

na

l A

nn

ua

l E

stim

ate

Year

Pool Chemical–associated Injuries, by Year

United States, NEISS, 2003–2012*

* Source: Hlavsa MC et al. MMWR 2014;63(19);427–30.

Pool Chemical–associated InjuriesUnited States, NEISS, 2012

� 4,876 (95% CI: 2,821–6,930) injuries

• 109 actual injuries diagnosed in NEISS ED’s

� Incident location

• 1,759 (95% CI: 718–2,799) occurred at residence

• 1,998 (95% CI: 1,057–2,940) occurred at unknown

location

� Patient disposition

• 4,394 (95% CI: 2,804–5,983) treated and released

or examined and released without treatment

• No deaths

Pool Chemical–associated InjuriesUnited States, NEISS, 2012

Data

Field

Actual

Count

Weighted

Estimate95% CI

Annual Rate

per 100,000

Injury diagnosis

Poisoning* 50 2,167 1,219–3,116 0.7

Dermatitis/

conjunctivitis33 1,581 385–2,778 —

Chemical burns 9 469 16–922 —

Other 17 657 234–1,081 —

Injured body part

All parts

(>50% of body)†55 2,218 1,269–3,167 0.7

Eyeball 34 1,525 572–2,478 —

Other 20 1,133 419–1,847 —* Poisoning includes ingestion as well as inhalation of vapors, fumes, or gases.† NEISS requires “All parts (>50% of body)” when poisoning is injury diagnosis.

Pool Chemical–associated InjuriesUnited States, NEISS, 2012

Patient

Demographic

Actual

Count

Weighted

Estimate95% CI

Annual Rate

per 100,000

Age (in years)

0–17 53 2,289 965–3,613 3.1

18–45 23 850 421–1,278 0.7

46–64 28 1,518 811–2,225 1.9

>65 5 218 0–441 —

Sex

Male 72 3,144 1,832–4,456 2.0

Female 37 1,731 894–2,569 1.1

Pool Chemical–associated InjuriesUnited States, NEISS, 2012

Patient

Demographic

Actual

Count

Weighted

Estimate95% CI

Annual Rate

per 100,000

Patient

race/ethnicity

White,non-

Hispanic (NH)

66 3,468 2,536–4,401 —

Black, NH 14 309 69–549 —

Hispanic 7 443 0–1,062 —

Other 1 6 0–18 —

Unknown 21 649 34–1,264 —

Day of WeekSeason

Summer*

Non-

Summer

Timing of Pool Chemical–associated

Health Events (n=109) — NEISS, 2012

Weekend

Weekday

* Saturday before Memorial Day (end of May)–Labor Day (beginning of September).

NEISS Narratives and Published Reports

� NEISS injuries frequently occurred when

• Handling without using personal protective

equipment

• Adding to water just before patient enters

– Frequently in hotel/motel or residential pools

• Failing to secure chemicals away from children

� Contributing factors

• Pool operators and residential pool owners lack

knowledge of basic pool chemical safety

• Standard pool equipment allows for situations

where concentrated chlorine and acid mix

Limitations of NEISS Data

� Underestimate

• Snapshot of only pool chemical–associated

injuries leading to ED visits

� Data Missing

• Incident location

• Patient race/ethnicity

� Misclassification of events possible

• Example: dermatitis resulting from Pseudomonas

infection or chemical exposure

� Water chemistry can change quickly making it

difficult to confirm exact chemical etiology

Treated Recreational Water–associatedIllness Outbreaks — United States, 2009–2010*

EtiologyLaboratory

ConfirmationOutbreak Count

Count of

Outbreak-

associated Cases

Infectious Confirmed 35 488

— 7 146

Chemical Confirmed 0 0

— 11 367

Unknown — 4 29

Total — 57 1,030

* Source: Hlavsa MC et al. MMWR 2014; 63(01);6-10.

Pool Chemical–associated Injuries

� Problem: Preventable

� Solution: 3E’s

• Enforcement: Model Aquatic Health Code (MAHC)

– Michael Beach: Today @ 13:40–14:00

• Education: Completing operator training which

include pool chemical safety (MAHC requirement)

• Engineering: Disabling chemical feed if

recirculation system at no or low flow (MAHC

requirement)

Resources

• Video available in

English* and

translated† into

o Spanish

o Portuguese

o French

o Russian

*English video developed by ACC and the U.S. Chlorine Institute.† Translations provided by the World Chlorine.

• FREE from CDC

thanks to the

American

Chemistry

Council (ACC)

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the

Centers for Disease Control and Prevention.

National Center for Emerging and Zoonotic Infectious Diseases

Healthy Swimming Program