Outbreaks of Short-Incubation Ocular and Respiratory Illness Following Exposure to Indoor Swimming Pools

Enteric Diseases Epidemiology Branch, National Center for Zoonotic, Vector-borne and Enteric Disease, Centers for Disease Control and Prevention, Atlanta, GA 30333 USA.
Environmental Health Perspectives (Impact Factor: 7.98). 03/2007; 115(2):267-71. DOI: 10.1289/ehp.9555
Source: PubMed


Chlorination destroys pathogens in swimming pool water, but by-products of chlorination can cause human illness. We investigated outbreaks of ocular and respiratory symptoms associated with chlorinated indoor swimming pools at two hotels.
We interviewed registered guests and companions who stayed at hotels X and Y within 2 days of outbreak onset. We performed bivariate and stratified analyses, calculated relative risks (RR), and conducted environmental investigations of indoor pool areas.
Of 77 guests at hotel X, 47 (61%) completed questionnaires. Among persons exposed to the indoor pool area, 22 (71%) of 31 developed ocular symptoms [RR = 24; 95% confidence interval (CI), 1.5-370], and 14 (45%) developed respiratory symptoms (RR = 6.8; 95% CI, 1.0-47) with a median duration of 10 hr (0.25-24 hr). We interviewed 30 (39%) of 77 registered persons and 59 unregistered companions at hotel Y. Among persons exposed to the indoor pool area, 41 (59%) of 69 developed ocular symptoms (RR = 24; 95% CI, 1.5-370), and 28 (41%) developed respiratory symptoms (RR = 17; 95% CI, 1.1-260) with a median duration of 2.5 hr (2 min-14 days). Four persons sought medical care. During the outbreak, the hotel X's ventilation system malfunctioned. Appropriate water and air samples were not available for laboratory analysis. CONCLUSIONS AND RELEVANCE TO PROFESSIONAL PRACTICE: Indoor pool areas were associated with illness in these outbreaks. A large proportion of bathers were affected; symptoms were consistent with chloramine exposure and were sometimes severe. Improved staff training, pool maintenance, and pool area ventilation could prevent future outbreaks.

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    • "However, the indoor environment is the most likely place for chloroform exposure for the general population due to the high ratios of indoor to outdoor air chloroform concentration, which are approximately 1–25 (Pellizzari et al., 1986). Although showering has been widely recognized to be the most significant contributor of DBPs from the various indoor uses of chlorinated tap water (Jo et al., 1990; Wilkes and Small, 1992), the contribution of DBPs in indoor swimming pools raises an issue worth greater health concerns (Aggazzotti et al., 1995; Aggazzotti et al., 1998; Lé vesque et al., 2000; Fantuzzi et al., 2001; Chu and Nieuwenhuijsen, 2002; Erdinger et al., 2004; Bowen et al., 2007). This is presumably because swimming pools generally utilize a water recirculation system for relatively long periods, due to which the concentration of DBPs in pool water may be expected to be higher than that in drinking water. "
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    ABSTRACT: Human exposure to chloroform in indoor swimming pools has been recognized as a potential health concern. Although environmental monitoring is a useful technique to investigate chloroform concentrations in indoor swimming-pool air, in practice, the interpretations of measured data would inevitably run into difficulties due to the complex interactions among the numerous variables, including environmental conditions and occupant activities. Considering of the relevant variables of environmental conditions and occupant activities, a mathematical model was first proposed to predict the chloroform concentration in indoor swimming-pool air. The developed model provides a straightforward, conceptually simple way to predict the indoor air chloroform concentration by calculating the mass flux, J, and the Péclet number, Pe, and by using a heuristic value of the indoor airflow recycle ratio, R. The good agreement between model simulation and measured data demonstrates the feasibility of using the presented model for indoor air quality management, operational guidelines and health-related risk assessment.
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    ABSTRACT: On December 26, 2006, the Nebraska Department of Health and Human Services (NDHHS) received a report of a child hospitalized in an intensive care unit for severe chemical epiglottitis and laryngotracheobronchitis after swimming in an indoor motel swimming pool. The pool was inspected the same day and immediately closed by NDHHS because of multiple state health code violations. NDHHS initiated an outbreak investigation to identify additional cases and the cause of the illness. This report describes the results of that investigation, which indicated that 24 persons became ill, and the outbreak likely was the result of exposure to toxic levels of chloramines* (1,2) that had accumulated in the air in the enclosed space above the swimming pool. This outbreak highlights the potential health risks from chemical exposure at improperly maintained pools and the need for properly trained pool operators to maintain water quality.
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