Hot tap water scalds prevention: A case for the power of public health partnerships in affecting regulatory change

That gleaming piece of plumbing hardware in daily use, the hot water tap, may seem innocuous and even stylish, and positively associated with clean clothes, clean dishes, and warm cozy baths, but paediatricians and public health professionals are painfully aware that there is another side to the story. That same tap is the household object that can serve up water that burns like fire, with devastating consequences; 150 severe and traumatic life-changing injuries to young children are reported across Canada annually (1). An additional 150 hot tap water injuries are endured by the elderly and individuals with disabilities each year (2,3).

For children, hot tap water injuries tend to be the most severe form of scalding injuries, and these burns typically cover a larger surface area than other scalds. In such cases, treatment often includes skin grafting on an ongoing basis. Children may not only suffer permanent physical scarring, but may also be emotionally traumatized. Elderly persons who sustain hot tap water scalds not only face prolonged hospitalization, but also are at a 50% increased risk of dying from their burns (M Gomez, personal communication) compared with other scald injuries requiring hospitalization. Individuals that are physically or mentally challenged are also at increased risk for severe hot tap water burns, with several injuries and even deaths occurring.

Hot water temperatures found in the home are typically 60°C (140°F). If exposed to water at this temperature, a young child’s skin will be severely burned in less than five seconds. In contrast, if hot water is at a temperature of 49°C, it will take more than two minutes for a serious burn injury to occur. The answer to preventing these injuries appears simple enough – reduce the hot tap water temperatures in homes from 60°C to around 49°C. Yet, there have been few advances in reducing hot tap water temperatures in Canadian homes until recently.

Safe Kids Canada, the national injury prevention program of The Hospital for Sick Children, took on the challenge of reducing these injuries. The approach included the acquisition of epidemiological data on the scope of the problem and contributing factors, an education program that included free hot water temperature cards as part of ‘Safe Kids Week’ (a national annual campaign), and a small team dedicated to seeking changes at the regulatory level. The team, which was formed in 2001, consisted of paediatric experts and injury prevention professionals with a specialist in healthy public policy advocacy. While hot tap water burns are a public health concern and a safety problem, regulatory solutions can only be achieved through changes in building codes and standards. Plumbing and building industry representatives, as well as regulators, predominantly develop these codes and standards. Over the last two decades, there has been only selective input from the public health, medical or injury prevention community. Safe Kids Canada became fully engaged with various interests in the regulatory mix within this framework, viewing public involvement as the most effective, and likely the only way, of changing policies and practices around hot tap water temperatures. This issue was first broached with regulators more than 25 years ago, but the approach had previously been to act primarily as advisors rather than full participants in the decision making process (4).

A change in the National Building and Plumbing Codes requiring reduced hot tap water temperatures could have significant impact on the spectrum of tap water scalds in Canada because the provinces and territories typically adopt the federal codes. In this way, hot water safety would be prescribed in the codes, leading to protective measures that are directly ‘built into’ newly constructed homes. As well, changes to product standards requiring reduced hot water temperatures in hot water storage tanks would also impact existing households, and old or nonconforming hot water tanks would be gradually replaced in homes. These passive measures would be important in reducing burn injuries by having the hot water taps provide hot, but not destructively hot, water. This strategy would complement all the other preventive activities parents take to keep their children safe.

To achieve these regulatory objectives, Safe Kids Canada set out to:

• build a coalition within the public health and medical community to get this issue to the top of the public health agenda;

• understand and engage in the processes necessary to bring changes to building codes and standards; and

• mount a campaign to influence those responsible for the codes and standards to improve home hot water temperature safety.

Safe Kids Canada first built awareness for the issue through coalition building in the public health and injury prevention field with organizations such as the Canadian Paediatric Society, the Council of Chief Medical Officers of Health, the Canadian Public Health Association, the Canadian Medical Association, and the College of Family Physicians of Canada. The support of these and other like-minded organizations was instrumental in raising the profile of the issue. (For a complete list of supporters please go to <www.safekidscanada.ca>)

Examples of the benefits of such support at the national, regional and local levels included:

• a resolution adopted at the Canadian Public Health Association annual meeting in 2001 to address this issue through changes to building codes and standards as proposed by Safe Kids Canada;

• participation from paediatricians at the Canadian Paediatric Society’s annual conference in a letter writing campaign and expert paediatric representation at critical code and standards meetings; and

• council resolutions were adopted by the Peel Region (Ontario) and the City of Toronto (Ontario) to support building code changes limiting home tap water temperatures at 49°C.

In addition, local studies testing hot water temperatures were undertaken. In some communities, such as Winnipeg and East York (Ontario), some families with populations known to be especially vulnerable, such as the elderly, those with skin insensitivity caused by diabetes and young children, were counselled about the dangers of overly hot water. These programs helped to raise awareness in communities.

In the Summer of 2001, a review of the National Building and Plumbing Codes was underway, and the timing was right for Safe Kids Canada to approach the Canadian Commission on Building and Fire Codes, the overseers of the code. The National Building and Plumbing Code is reviewed every five years and consultation on proposed amendments had already begun. Safe Kids Canada made a presentation to the Commission, including its several technical committees, which outlined the issue and presented etiological and epidemiological facts. Data was presented on hot tap water injuries from the Canadian Hospital Injury Reporting Prevention Program at Health Canada. The agency tracks the number and types of injuries that occur in selected hospitals across the country. Furthermore, a policy review of other countries’ approaches in addressing the issue, particularly in the United States, showed that Canada was behind in addressing this health issue. Real life stories from surgeons, paediatricians and families that were impacted by a burn injury were also brought forward. The compelling evidence combined with real life stories made a real impression on Commission members. In addition, this information was presented to the Canadian Standards Association, which is responsible for standards for hot water tank products and plumbing devices.

While there was general agreement that hot tap water safety needed to be improved through both bodies, industry representatives and regulators were concerned about how to achieve tempered water reductions. A consensus approach was undertaken to determine how these respective changes would occur. In the code process and standards process, some members of the industry and regulators favoured the use of plumbing devices over reducing hot water thermostats at the single-family hot water tank to achieve temperature reductions. In the United States, manufacturers of hot water tanks have been presetting hot water tanks at 49°C for more than 20 years. A study in the state of Washington, where water heaters were mandated to be set at 49°C, showed a decrease in severe injuries by 50% (5).

The overriding concern about lowering temperatures in hot water heaters in single-family dwellings was the possibility of an increased risk of legionellosis. The industry had numerous articles in trade magazines by plumbers and others in the contracting industry identifying legionellosis as a major safety concern in reducing temperatures at the tank.

Safe Kids Canada deferred to the experts on infectious disease and infection control at Health Canada and requested a review of the scientific studies concerning temperature reductions in hot water tanks and the risks of legionellosis. A report was issued by Health Canada supporting temperature reductions in hot water tanks as a viable and safe approach to reducing scald burn injuries, but advised that people with certain medical conditions should check with their doctors before reducing the temperature of the water in their homes. These conditions include a weakened immune system, lung and respiratory problems, or organ transplants. However, Health Canada concluded that most families can safely lower their water temperature to 49°C without concern for other health risks. The Canadian Hospital Infection Control Association reviewed and agreed with this position.

However, even these reports were not enough to bring about consensus on the issue. While the majority of the public health community provided support for reducing thermostat settings for single-family homes, those from the province of Quebec were still suggesting a precautionary principle approach vis a vis the risk of legionellosis. Other public health groups supported the view that the very real risk of scald injuries outweighed the potential risk of legionellosis, especially since the American experience did not show an increase in legionellosis with the reduced temperatures.

In order to have a full discussion and debate on the issue, a summary document was created by Safe Kids Canada outlining the case in favour of making regulatory and product standards changes as a key way of addressing hot tap water injuries. This document was a culmination of gathered research that supported the need to mandate lower temperatures. The document was sent to decision makers and to injury prevention partners as a call for action to support the changes. The document was also sent to provincial and territorial government departments responsible for health and for the building codes in various provinces and territories.

The response to the request for support was high. More than 300 letters from across Canada were collected, including letters from Canada’s Minister of Health. In addition, many paediatricians submitted personal stories of the devastation caused by unnecessarily high tap water temperatures found in homes. Increased profile, resulting from influential, compassionate and activated paediatricians and public health individuals, helped the campaign gain momentum, despite the fact that the process of reviewing building codes and standards is highly technical and administrative. The coalition that supported safe hot water was successful in opening a technical process that is typically closed to a more public debate.

After three years into the process of requesting codes and standards amendments, progress has been made. A change to the National Plumbing Code requiring hot tap water temperatures not to exceed 49°C is expected to be finalized in the spring of this year. At the time of writing, standards for presetting hot water tanks to 49°C or using safety devices to lower temperatures have been issued by the Canadian Standards Association for electrical and oil fueled hot water tanks. Both safety initiatives should come into effect in 2005.

Input from paediatricians, health practitioners, families, and local, regional and public health officials were needed to move this important health issue forward on the agenda for change that was stymied in the past. Consensus building, while time consuming and at times onerous, rarely generates headlines, but it can significantly influence public health policies and achieve a ‘win’ for all, most of all, for the children.