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Healh risks of early swimming pool attendance
Abstract
Swimming pool attendance and exposure to chlorination by-products showed adverse health effects on children. We assessed whether early swimming pool attendance, especially baby swimming, is related to higher rates of early infections and to the development of allergic diseases. In 2003-2005, 2192 children were analysed for the 6-year follow-up of a prospective birth cohort study. Data on early swimming pool attendance, other lifestyle factors and medical history were collected by parental-administered questionnaire. Bivariate and multivariate logistic regression analyses were used to evaluate associations. Babies who did not participate in baby swimming had lower rates of infection in the 1st year of life (i) diarrhoea: OR 0.68 CI 95% 0.54-0.85; (ii) otitis media: OR 0.81 CI 95% 0.62-1.05; (iii) airway infections: OR 0.85 CI 95% 0.67-1.09. No clear association could be found between late or non-swimmers and atopic dermatitis or hay fever until the age of 6 years, while higher rates of asthma were found (OR 2.15 95% CI 1.16-3.99), however, potentially due to reverse causation. The study indicates that, in terms of infections, baby swimming might not be as harmless as commonly thought. Further evidence is needed to make conclusions if the current regulations on chlorine in Germany might not protect swimming pool attendees from an increased risk of gastrointestinal infections. In terms of developing atopic diseases there is no verifiable detrimental effect of early swimming.
... Two studies reported the risk of diarrhea and/or giardia proliferation and contamination in infant swimming groups [32,34]. The chance of having diarrhea was lower for infants who never attended swimming groups or attended only after the first year of life compared to those who attended the pool earlier [34]. ...
... Two studies reported the risk of diarrhea and/or giardia proliferation and contamination in infant swimming groups [32,34]. The chance of having diarrhea was lower for infants who never attended swimming groups or attended only after the first year of life compared to those who attended the pool earlier [34]. Even in properly treated swimming pools, the participation of children infected with giardia seems to be an agent of contamination to other children attending in swimming programs [32]. ...
... Baby swimming programs increased the likelihood of wheeze in infants with a maternal history of atopy. Five studies investigated the effect of swimming pool attendance on infants' lower respiratory tract infections (LRTI) [33][34][35][36][37], and in all five studies, no evidence of an association was observed. However, infants' recurrent respiratory tract infections [33] and increased risk of wheezing [35] were associated with atopic parents (i.e., possessing an extremely sensitive form of allergy). ...
This systematic review investigated the possible effects of exposing infants to formal activities in aquatic environments. A literature search of eight databases was concluded on 12 December 2022. Studies were eligible if they: (i) focused on 0-36 months of age infants, (ii) addressed the exposure of infants to formal aquatic activities, and (iii) compared the 'same condition of aquatic exposure with the control' or 'before and after exposure'. The PRISMA protocol was used. Articles considered for inclusion (n = 18) were clustered in the health, development, and physiological outcome domains. The results show that research is focused on indoor activities, mainly in baby swimming programs and baby aquatic therapy interventions. Swimming and aquatic therapy practices are generally safe for babies' health, and there are benefits to preterm and newborns exposed to aquatic therapy once the physiological parameters are maintained in normal and safe patterns. A positive effect is also suggested in general gross and fine motor skills, visual motion perception, cognitive flexibility, and response selection accuracy for infants who participated in aquatic programs. Further investigation with high-quality experimental designs is required to establish the effect of exposure of infants to formal aquatic activities (Systematic Review Registration: CRD42021248054).
... Par ailleurs, une étude allemande a montré que les bébés nageurs présentent un risque accru de diarrhées au cours de leur première année, mais sans risque supérieur de maladie allergiques jusqu'à 6 ans (Schoefer et al., 2008). Cependant, selon cette étude, les enfants non bébés nageurs présenteraient un risque supérieur de développer un asthme. ...
... Ceci pourrait s'expliquer par le fait que les limites règlementaires en chlore combiné dans l'eau des piscines allemandes sont inférieures aux limites des autres pays, dont la Belgique. Schoefer conclue à l'hypothèse selon laquelle le seuil en chlore combiné pratiqué en Allemagne pourrait protéger les enfants contre le développement de maladies allergiques, mais que les conditions de traitement de l'eau seraient alors insuffisantes pour la désinfecter de manière adéquate, d'où l'augmentation de maladies infectieuses (Schoefer et al., 2008). ...
... Sin embargo, en piscinas de electrólisis salina la concentración de THM varía, siendo en algunos casos superior (Lee et al., 2009) o inferior a las piscinas cloradas (Jacobs et al., 2007). Tomando como referencia la correlación positiva entre los problemas de salud y la presencia de DBPs en el agua, se produciría en teoría una disminución de los primeros al utilizar trata-Exis te relación entre la asistencia a la piscina durante la lactancia e infancia con el padecimiento de bronquiolitis 5-6 430 Historial clínico y cuestionario sobre hábitos y síntomas res piratorios Voisin et al., 2010 Exis te relación entre la asistencia de la piscina durante lactancia e infancia con sín tomas de asma y rinitis alérgica 9-12 3223 Cuestionario sobre hábitos y síntomas respiratorios durante los últimos 12 meses Font-R ibera et al., 2009 Se producen un mayor porcentaje de infecciones en las vías aéreas de bebés n adadores con menos de un año respecto a bebés no nadadores, así co mo la asis tencia prematura a la piscina está relacionada una mayor probabilidad de padecer asma a l os 6 años 1-6 2192 Historial clínico y cuestionario sobre hábitos y síntomas res piratorios Schoefer et al., 2008 Se halló una correlación entre los niveles de CC16 con la asistencia de piscinas cubiertas únicamente en niñas (n=136) 5-6 233 Concentraciones de CC16, albumina y urea en líquido nasal. IgE en la muscosa nasal Sardella et al., 2013 Los niños que asistieron a la piscina durante la lactancia mostraron niveles más altos de SP-D y más bajos de CC16 13-16 341 ...
... Nystad, Nja, Magnus y Nafstad (2003) establecieron un porcentaje significativamente más alto de padecimiento de infecciones respiratorias y auditivas en niños que habían asistido durante la lactancia a natación respecto a los niños que no lo habían hecho. En la misma línea, Kohlhammer, Döring, Schäfer, Wichmann y Heinrich (2006) observaron que la asistencia a la piscina durante la edad escolar tienen una relación directa con una mayor sensibilidad a los alérgenos, y Schoefer et al. (2008) hallaron un mayor índice de infecciones en las vías aéreas de bebés nadadores con menos de un año, así como una mayor probabilidad de padecer asma a los 6 años. Un estudio similar llevado a cabo en España por Font-Ribera et al. (2009) estableció relaciones entre la asistencia durante el periodo de lactancia a piscinas con una mayor presencia de rinitis alérgica, y síntomas de asma. ...
El objetivo de este trabajo fue identificar los tratamientos químicos del agua utilizados en piscinas cubiertas y los métodos para evaluar sus efectos en la función y aparato respiratorio de diferentes poblaciones asistentes a estas instalaciones. Se realizó una búsqueda de publicaciones científicas y libros sobre los tratamientos químicos en piscinas y sus efectos en la salud y la función respiratoria. Los tratamientos químicos en piscina basados en el cloro y el bromo generan subproductos de desinfección dañinos para el organismo (DBPs) como las cloraminas y los trihalomentanos (THM). Existen tratamientos alternativos como ultravioleta y ozono que reducen la formación de DBPs. Los métodos de evaluación utilizados para detectar enfermedades, daño pulmonar y de las vías respiratorias son las técnicas basadas en la espirometría, y el análisis de biomarcadores en plasma o suero sanguíneo (proteínas CC16, surfactantes A, B y D, Inmunoglobulina específica), aire exhalado (óxido nítrico, citoquinas), orina (CC16, leukotrieno B4), esputo o saliva (eosinofilos y linfocitos) y DBPs en aire exhalado, sangre u orina. Los efectos observados en las diferentes poblaciones han sido el aumento de la permeabilidad del epitelio pulmonar, la inflamación de las vías respiratorias y síntomas asociados al asma, hiper-reactividad bronquial y rinitis alérgica. Los efectos negativos detectados en el aparato respiratorio de las diferentes poblaciones en piscinas están relacionados con la exposición a productos químicos. Algunos Biomarcadores (como la proteína CC16) obtienen una mayor fiabilidad. Los tratamientos complementarios (ozono y ultravioleta) no han sido evaluados y pueden suponer una reducción en los problemas respiratorios de nadadores y trabajadores.Palabras Clave: biomarcadores, enfermedades respiratorias, espirometría, natación, subproductos de desinfección.Abstrac: The aim of this study was to identify the effects on respiratory function produced by water chemical treatments in the indoor pools in different populations. We made a review of the scientific literature about chemical treatments of water and assessment methods used to detect health effects and respiratory function. Chemical treatments chlorine and bromine generate disinfection byproducts (DBPs) that are harmful to the body, such as chloramines and trihalomethanes (THM). There exist alternative treatments such as ultraviolet radiation and ozone to reduce the formation of DBPs. The methods used to detect diseases of the respiratory tract are spirometry, analysis of biomarkers in plasma or serum (CC16 proteins, surfactants A, B and D, etc..) and exhaled air (nitric oxide, cytokines). The health problems that have been observed are the increase in lung epithelial permeability, inflammation of the airways and other symptoms associated with asthma, allergic rhinitis and bronchial hyper reactivity. The negative effects on respiratory function are related to prolonged exposure to chemicals (chlorine and bromine) in indoor swimming pools. Some biomarkers such as protein CC16 obtain greater reliability as a measurable variable. The reduced presence of DBPs in combination water treatments may be a way to reduce respiratory problems. However, more research is needed for confirmation.Key words: biomarkers, disinfection by products, lung diseases, spirometry, swimming.
... Par ailleurs, une étude allemande a montré que les bébés nageurs présentent un risque accru de diarrhées au cours de leur première année, mais sans risque supérieur de maladie allergiques jusqu'à 6 ans (Schoefer et al., 2008). Cependant, selon cette étude, les enfants non bébés nageurs présenteraient un risque supérieur de développer un asthme. ...
... Ceci pourrait s'expliquer par le fait que les limites règlementaires en chlore combiné dans l'eau des piscines allemandes sont inférieures aux limites des autres pays, dont la Belgique. Schoefer conclue à l'hypothèse selon laquelle le seuil en chlore combiné pratiqué en Allemagne pourrait protéger les enfants contre le développement de maladies allergiques, mais que les conditions de traitement de l'eau seraient alors insuffisantes pour la désinfecter de manière adéquate, d'où l'augmentation de maladies infectieuses (Schoefer et al., 2008). ...
... Επίδραση του χλωρίου στη βρεφική, παιδική και εφηβική ηλικία Η κολύμβηση είναι από τα λιγοστά αθλήματα που μπορεί να ξεκινήσει η εκγύμναση από πολύ μικρή ηλικία, ακόμα και από τη βρεφική. Παρ' όλα ταύτα η επίδραση του χλωρίου στο αδιαμόρφωτο και συνεχώς αναπτυσσόμενο σώμα των βρεφών μπορεί να δημιουργήσει προβλήματα σύμφωνα με συγκεκριμένους ερευνητές (ΜcMaster, 2011;Schoefer, et al., 2008;Voisin, et al., 2010). Δυστυχώς δεν μπορούμε να εξάγουμε ασφαλή συμπεράσματα όσον αφορά στο χλώριο στη βρεφική ηλικία, διότι το εύρος των ερευνών είναι ιδιαίτερα μικρό, μπορεί όμως να αποτελέσει εφαλτήριο για περισσότερη ενασχόληση με το καίριο αυτό ζήτημα μελλοντικά. ...
... Η κολύμβηση είναι από τα λιγοστά αθλήματα που μπορεί να ξεκινήσει η εκγύμναση από πολύ μικρή ηλικία, ακόμα και από τη βρεφική. Εντούτοις, σύμφωνα με συγκεκριμένους ερευνητές (ΜcMaster, 2011;Schoefer, et al., 2008;Voisin, et al., 2010), η επίδραση του χλωρίου στο αδιαμόρφωτο και συνεχώς αναπτυσσόμενο σώμα των βρεφών μπορεί να δημιουργήσει προβλήματα. Δυστυχώς, όμως και σ' αυτή την περίπτωση όπως και σε άλλες που αναφέραμε σε άλλα μέρη αυτής της βιβλιογραφικής ανασκόπησης δεν μπορούμε να εξάγουμε ασφαλή συμπεράσματα όσον αφορά στην επίδραση του χλωρίου στα βρέφη, διότι το μέγεθος των ερευνών είναι ιδιαίτερα μικρό. ...
Chlorine is an important factor of disinfection water in swimming pools and used extensively over the past decades. The most commonly used product is the sodiumorcalcium hypochlorite, but other chlorine compounds such as dichloroisocyanurateorchlorine gas are sometimes used. Nowadays there is an attempt across Europe to lower the use of chlorine by aparallel use of ozone, but in Greece the utilization of chlorine is dominantin nearly all swimming pools that operate such assports areas and recreational choices. The literature revie, highlighted by the majority of studies the harmful importance of chlorinemainly in indoor swimming pools and proposed alternative disinfection methods such as ionization. This does notdetract from the significance of chlorine as a disinfectant, but high point the appropriate measures (pre-washing, keeping hygiene, proper ventilation), so as to maximize the benefits of its use.
... Ces effets pourraient être le résultat d'inhalations répétées de produits chlorés, sous forme de gaz, d'aérosols et d'eau. Voisin et Bernard (2008) ont montré chez les enfants de plus de 2 ans que la prévalence de l'asthme serait fortement corrélée avec le temps cumulé passé dans une piscine chlorée (Voisin et Bernard, 2008 Par ailleurs, une étude allemande a montré que les bébés nageurs présentent un risque accru de diarrhées au cours de leur première année, mais sans risque supérieur de maladie allergiques jusqu'à 6 ans (Schoefer et al., 2008). Cependant, selon cette étude, les enfants non bébés nageurs présenteraient un risque supérieur de développer un asthme. ...
... Ceci pourrait s'expliquer par le fait que les limites règlementaires en chlore combiné dans l'eau des piscines allemandes sont inférieures aux limites des autres pays, dont la Belgique. Schoefer conclue à l'hypothèse selon laquelle le seuil en chlore combiné pratiqué en Allemagne pourrait protéger les enfants contre le développement de maladies allergiques, mais que les conditions de traitement de l'eau seraient alors insuffisantes pour la désinfecter de manière adéquate, d'où l'augmentation de maladies infectieuses (Schoefer et al., 2008). ...
... Residu klorin ini diketegorikan sebagai zat kimia yang berbahaya bagi kesehatan. Selain itu sebagai salah satu syarat untuk memenuhi sanitasi dan hygiene yang baik, maka perlu dilakukan analisa tentang residu klorin ini (Schoefer et al, 2008). ...
... Chlorine or other disinfectants used in swimming pools are less effective at higher temperatures, reducing their ability to kill harmful bacteria and viruses. This is dangerous for the health of swimmers [11,42]. The temperature of thejacuzzi in Ghaneian's study in Yazd was 38 oc , and in the study of Mosaferi in Tabirz, the temperature was 41.1 oc , which is higher than the standard, of course, because of the interest and request of Iranian swimmers and their request to increase the temperature. ...
Swimming pools rank high among dangerous places for human recreation, which play an important role due to the high number of references and require continuous monitoring of pollutants and factors affecting it. Therefore, this study was conducted with the aim of systematically investigating the relationship between chlorine and heterotrophs in published studies in Iran. PubMed, Science Direct, and Google Scholar databases were searched from April 2000 to September 2022. Then identified studies were evaluated, then the studies lacking the necessary quality were excluded. From 686 articles, 33 reputable studied investigated the concentration of free chlorine in Iranian pool water. However, 14 studies measured the free chlorine and heterotrophs in swimming pools of 12 different Iranian cities. According to the results of the present study, the appropriate residual chlorine has reduced the microbial contamination of the pools, also, using the clarification in conjunction with the remaining free chlorine concentration, can help ensure the bacteriological quality of the water in the swimming pool. So maintaining the residual chlorine levels and daily cleaning of the pool can be effective in controlling heterotrophs in swimming pools and water recreational environments.
... atopiky. Výzkum Schoefera et al. (2008), kteří se zaměřují na spojitost tzv. baby plavání a možných rizik kožních chorob, nepotvrzuje možnost, že by plavecký výcvik přispíval ke spuštění atopického ekzému. ...
... The average maintenance of trichloramine in the swimming pools has no effect on children's health in terms of respiratory problems, asthma, or atopy (Jacobs et al., 2012). The research was conducted in European countries like Germany (Schoefer et al., 2008), Spain (Font-Ribera et al., 2009, the Netherlands (Jacobs et al., 2012), and the UK (Font-Ribera et al., 2011) found no relationship. According to WHO, the exposure of trichloramine lesser than 0.5 μg/ml has no effect on the children's health condition (Bernard et al., 2007(Bernard et al., , 2009Jacobs et al., 2012). ...
Water contamination through anthropogenic and industrial activities has led to the emergence and necessity of disinfection methods. Chlorine and bromine gases, often used to disinfect water, resulted in the by-product formation by reacting with organic matter. The Disinfectant by-products (DBP) led to the formation of Trihaloaceticacid (TAA), Trihalomethane (THM), and other minor components. The release of chemicals has also led to the outbreak of diseases like infertility, asthma, stillbirth, and types of cancer. There are new approaches that are found to be useful to compensate for the generation of toxic by-products and involve membrane technologies, namely reverse osmosis, ultrafiltration, and nanofiltration. This review mainly focuses on the toxicology effects of DBPs and various approaches to mitigate the same. The health hazards caused by different DBPs and the various treatment techniques available for the removal are discussed. In addition, a critical comparison of the different removal techniques was discussed.
... 133 Fortunately, medical problems from swimming are rare, treatable, and preventable events. 134,135 The World Aquatic Babies and Children Network has published guidelines for the operation of aquatic programs for children younger than 3 years. The guidelines recommend (1) required parental involvement, (2) a fun atmosphere with one-onone teaching, (3) qualified teachers, (4) warm water to prevent hypothermia, (5) maintenance of water purity, and (6) a limited number of submersions to prevent water ingestion and hyponatremia. ...
Drowning is a leading cause of injury-related death in children. In 2018, almost 900 US children younger than 20 years died of drowning. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in prevention of drowning.
... Inhalation, cutaneous exposure, and ingestion of irritant and carcinogenic disinfection byproducts (DBPs) have all been implicated in human pathogenesis (such as respiratory impairment and asthma exacerbation, allergic contact dermatitis, ocular/corneal irritation, and bladder cancer, respectively) [12,16]. Indeed, epidemiological evidence suggests that pool attendance correlates with increased asthma incidence in Olympic swimmers and pool workers, and consequences of HOCl exposure are now recognized as a potential public health concern [10,[17][18][19][20]. ...
Hypochlorous acid (HOCl) is the active oxidizing principle underlying drinking water disinfection, also delivered by numerous skin disinfectants and released by standard swimming pool chemicals used on a global scale, a topic of particular relevance in the context of the ongoing COVID-19 pandemic. However, the cutaneous consequences of human exposure to HOCl remain largely unknown, posing a major public health concern. Here, for the first time, we have profiled the HOCl-induced stress response in reconstructed human epidermis and SKH-1 hairless mouse skin. In addition, we have investigated the molecular consequences of solar simulated ultraviolet (UV) radiation and HOCl combinations, a procedure mimicking co-exposure experienced for example by recreational swimmers exposed to both HOCl (pool disinfectant) and UV (solar radiation). First, gene expression elicited by acute topical HOCl exposure was profiled in organotypic human reconstructed epidermis. Next, co-exposure studies (combining topical HOCl and UV) performed in SKH-1 hairless mouse skin revealed that the HOCl-induced cutaneous stress response blocks redox and inflammatory gene expression elicited by subsequent acute UV exposure (Nos2, Ptgs2, Hmox1, Srxn1), a finding consistent with emerging clinical evidence in support of a therapeutic role of topical HOCl formulations for the suppression of inflammatory skin conditions (e.g. atopic dermatitis, psoriasis). Likewise, in AP-1 transgenic SKH-1 luciferase-reporter mice, topical HOCl suppressed UV-induced inflammatory signaling assessed by bioluminescent imaging and gene expression analysis. In the SKH-1 high-risk mouse model of UV-induced human keratinocytic skin cancer, topical HOCl blocked tumorigenic progression and inflammatory gene expression (Ptgs2, Il19, Tlr4), confirmed by immunohistochemical analysis including 3-chloro-tyrosine-epitopes. These data illuminate the molecular consequences of HOCl-exposure in cutaneous organotypic and murine models assessing inflammatory gene expression and modulation of UV-induced carcinogenesis. If translatable to human skin these observations provide novel insights on molecular consequences of chlorination stress relevant to environmental exposure and therapeutic intervention.
... Los procesos inflamatorios secundarios y la remodelación de las vías respiratorias condicionan síntomas respiratorios crónicos que precisan de tratamientos y pueden disminuir la calidad de vida de las personas expuestas. 27 Las investigaciones actuales se han dedicado a estudiar los mecanismos por los cuales se documenta una alta prevalencia de hiperreactividad de las vías respiratorias de nadadores o trabajadores de piscinas cubiertas. Recientemente se ha documentado que los nadadores de piscinas cubiertas expresan conteos de células inflamatorias mayores www.medigraphic.org.mx 12 horas después de los entrenamientos. ...
Disinfection by-products (DBP) are the result of the reaction of disinfectants (such as chlorine) with natural organic matter and are present in swimming pool water and in residential sources such as drinking water, the shower and the bathroom. There are studies which have shown the health effects of exposure to DBP on airway dysfunction and other respiratory complications. It has been documented that these products can irritate both the upper and lower respiratory tract and induce various respiratory symptoms particularly in children and high level swimmers. A natural pool (also called ecological pools, naturalized pools, bio-pools) is a pool where, to achieve the necessary water quality, a natural purification system is used instead of using chemicals. More and more evidence suggests that they can be an alternative to chlorinated swimming pools, eliminating the need for chemical treatment and expenses in mechanical and electrical processes, minimizing pumping requirements and also, reducing the potential irritating effect to the airway.
... Longer stay in indoor swimming pool halls, from which THMs are not effectively removed, can cause cancer, occupational asthma, rhinitis, upper respiratory tract diseases, and skin and eye irritation [33]. Especially harmful is the effect of THM on children's organisms in school swimming pools with bad water quality [34][35][36][37]. Therefore, it seems advisable to carry out works aimed to monitor and improve the functioning of the most important technological systems (also related to ensuring appropriate water parameters). ...
The most common cause of diseases in swimming pools is the lack of sanitary control of water quality; water may contain microbiological and chemical contaminants. Among the people most at risk of infection are children, pregnant women, and immunocompromised people. The origin of the problem is a need to develop a system that can predict the formation of chlorine water disinfection by-products, such as trihalomethanes (THMs). THMs are volatile organic compounds from the group of alkyl halides, carcinogenic, mutagenic, teratogenic, and bioaccumulating. Long-term exposure, even to low concentrations of THM in water and air, may result in damage to the liver, kidneys, thyroid gland, or nervous system. This article focuses on analysis of the kinetics of swimming pool water reaction in analytical device reproducing its circulation on a small scale. The designed and constructed analytical device is based on the SIMATIC S7-1200 PLC driver of SIEMENS Company. The HMI KPT panel of SIEMENS Company enables monitoring the process and control individual elements of device. Value of the reaction rate constant of free chlorine decomposition gives us qualitative information about water quality, it is also strictly connected to the kinetics of the reaction. Based on the experiment results, the value of reaction rate constant was determined as a linear change of the natural logarithm of free chlorine concentration over time. The experimental value of activation energy based on the directional coefficient is equal to 76.0 [kJ×mol−1]. These results indicate that changing water temperature does not cause any changes in the reaction rate, while it still affects the value of the reaction rate constant. Using the analytical device, it is possible to constantly monitor the values of reaction rate constant and activation energy, which can be used to develop a new way to assess pool water quality.
... In addition, children swallow water more often than adults. Therefore, it is important to strictly adhere to the recommendations regarding the permissible concentration of combined chlorine and strive to keep the concentration as low as possible [2,7,9,59,60]. ...
The main objective of this research was to determine the possibility of using the highly ozonated water for the pre-ozonation process as a complementary process to the conventional pool water treatment method. In the tested facility, contamination with P. aeruginosa, accompanying over-normative colony forming unit of total number of bacteria and a high content of combined chlorine (>0.3 mg Cl 2 /L in pool water and >0.2 mg Cl 2 /L in circulating water) and chloroform, was a basic problem related to water quality that caused the swimming pools to be excluded from an operation on several occasions. The research was divided into three parts. In each part, the quality of pool water was assessed in relation to the applicable requirements in this respect. In the first part, the quality of water treated in a conventional system was evaluated. In the second part, a mobile system for the production and dosage of highly ozonated water (SPID-WOFIL ®) was included in the water treatment system (before the proper filtration system). In this part, several preliminary tasks were performed in order to prepare the ozonation system for operation on an everyday basis. In the third part, a sequential water pre-ozonation process was established. As a result of the pre-ozonation process (0.3-0.6 mg O 3 /L dose), protection against microbiological water contamination and reduction of the content of selected DBP (chloramines: 12%-48%, trihalomethane: 35%-71%, and chloroform 4%-96%) was achieved.
... Aunque en las últimas décadas se han realizado diversos estudios dónde se relacionaba la incidencia de patología respiratoria, otitis, dermatitis, etc. en bebés que practican actividad acuática (Nystad, Njå, Magnus & Nafstad, 2003;Schoefer et al 2008), los resultados no están claros entre la causa-efecto, más bien solo han sugerido la posibilidad de influencia del cloro sobre las vías respiratorias (Bernard, Voisin & Sardella, 2011), además otros estudios posteriores con muestras superiores han destacado lo contrario "No se detectó asociación entre la asistencia a la piscina y el LRTI, sibilancias, tos persistente, eccema atópico u otitis durante el primer año de vida en España" (Font-Ribera et al 2013). ...
Introducción El presente estudio, parte de una revisión bibliográfica anterior sobre las técnicas de tratamiento en piscina para los pacientes afectados de Parálisis Cerebral Infantil (PC). Al no encontrar diferencias significativas entre los distintos métodos y técnicas utilizados, diseñamos un programa de ejercicios según el modelo del desarrollo psicomotor del niño sano, implementándolo y valorando su eficacia en el tratamiento de personas con esta patología haciendo un uso de la hidroterapia orientado hacia los aspectos estructurales, funcionales y sociales en el proceso global de la rehabilitación. Objetivos El objetivo de este estudio es valorar la evolución que se produce en la función motora gruesa en niños afectados de PC, después de seis meses de tratamiento. Material y métodos Se trata de un estudio longitudinal prospectivo sobre 12 pacientes con edades comprendidas entre 18 y 33 meses al comienzo, 9 niños y 3 niñas. El protocolo de tratamiento consiste en una sesión semanal de 30 minutos de los cuales, 20 se realizan íntegramente en piscina. Se evaluó mediante la Escala validada Gross Motor Function Measure (GMFM) antes de realizar hidroterapia y a los seis meses de iniciar la intervención. No se ha utilizado grupo control debido a que la diversa sintomatología propia de esta patología lo desaconseja. Cada paciente es su propio control entre el pre y post-test. Resultados Se observa una mejoría, estadísticamente significativa, en la escala global GMFM y en aspectos específicos de las subescalas: a) Tumbado y rodando, b) Sentado, c) Gateando y de rodillas, d) de pie, e) Andando, Corriendo, saltando. Conclusiones La hidroterapia promueve el desarrollo de habilidades motoras gruesas en niños afectados por PC. También contribuye a un desarrollo positivo en la curva GMFM normal y una mejora posterior a la intervención en los percentiles correspondientes.
... However, according to the researcher, this effect could also have had causes other than exposure to chlorine compounds. No association was found between swimming in chlorinated water during the neonatal period and increased frequency of occurrence of atopic dermatitis or pollinosis during the 6-year observation [30]. ...
Indoor swimming pools can be used all year round and serve for one of the most popular sport pursued for recreation. The positive effect of swimming arises in particular from the involvement of all the muscles of the body, decreasing the burden on the joints, as well as functional improvement of both the lungs and heart. Chlorine is typically used to disinfect swimming pool water and as a result the changes that take place lead to the formation of by-products, such as monochloramines (NH2Cl), dichloramines (NH2Cl2) i trichloramines (NH2Cl3), trihalogenometans (THM) or haloacetic acid (HAA). The highest concentration of these substances is just above the water surface and they may cause irritation of skin, eyes and mucosa of the respiratory tract. The toxic effect of high chlorine concentration and its side-products on the respiratory system is known, but the effect of low concentrations of these compounds is still not fully determined. Recent studies suggest that development of allergic diseases among swimmers may be increased by epithelial disorders driven by airway barrier dysfunction caused by chlorine irritation. Swimming in chlorinated water may be linked to symptoms of bronchial hyperreactivity, asthma and rhinitis especially in children, elite swimmers and employees of indoor swimming pools. Hypersensivity pneumonitis related to the use of swimming pools may manifest as a swimming pool or sauna user lung, most commonly caused by water polluting pathogens. The article summarizes recent data concerning the influence of chlorinated water on the development of allergic diseases.
... Menurut Vina (2010), saat tidur nyenyak pertumbuhan otak bayi akan mencapai puncaknya karena tubuh bayi akan memproduksi hormon pertumbuhan tiga kali lebih banyak daripada ketika bayi terjaga. Oleh karena itu, bayi yang tidurnya lebih lama pertumbuhan dan perkembangan bayi akan tercapai secara optimal dan memungkinkan tubuh memperbaiki dan memperbarui seluruh sel yang ada di dalam tubuh (Helen et al., 2005;Prase-tyono, 2012;Schoefer et al., 2007;Widiyanti et al., 2008). ...
... [108] [109] Mould and dampness exposure in early life Increased risk of asthma in young children and allergic rhinitis symptoms in school-age children [110] Indoor renovation activities Increased inflammatory markers [111] Early swimming pool attendance More diarrhea, otitis media (ns) and airway infections (ns) [112] Early life otitis media Incident atopic disease at school age [113] traffic-related air pollution More atopic diseases, allergic sensitization ...
Did you ever hear about epidemiology in Germany? Starting from an epidemiological desert the discipline has grown remarkably, especially during the last 10–15 years: research institutes have been established, research funding has improved, multiple curriculae in Epidemiology and Public Health are offered. This increase has been quite steep, and now the epidemiological infrastructure is much better. Several medium-sized and even big population cohorts are ongoing, and the number and quality of publications from German epidemiologists has reached a respectable level. My own career in epidemiology started in the field of environmental health. After German reunification I concentrated for many years on environmental problems in East Germany and observed the health benefits after improvement of the situation. Later, I concentrated on population-based cohorts in newborns (GINI/LISA) and adults (KORA, German National Cohort), and on biobanking. This Essay describes the development in Germany after worldwar 2, illustrated by examples of research results and build-up of epidemiological infractructures worth mentioning.
... Fig. 1) with respect to the original (OR, 1.084; 95% CI: 0.89-1.31). 2,[7][8][9][10][11][12][13] Regarding the other criticisms, in the study with adults aged 34-70 years, it was possible to disaggregate data, acquiring only those related to school-age subjects. With regard to the Avon Longitudinal Study of Parents and Children (ALSPAC), 10 it was evaluated in the same way as all the other studies. ...
... Babyschwimmen zählt zu den häufigen Bewegungsangeboten für Säuglinge. Hier wird der mögliche Nutzen gegenüber den erhöhten Risiken, insbesondere auch für Infektionen, kontrovers eingeschätzt [169,193]. Grundlagen der Empfehlungen. Aufgrund der entwicklungsphysiologisch abgeleiteten Bedeutung von Bewegung sollte die Bewegungszeit so wenig wie möglich begrenzt werden. ...
Im 1. Lebensjahr wachst und entwickelt sich der Mensch am schnellsten in seinem Leben. Daraus ergeben
sich besondere Anforderungen an die Ernahrung. Fur Eltern ist es oft eine sensible Phase, in der sie
alles richtig machen mochten. Hier liegt eine grose Chance fur die Beratung. Schlieslich werden bereits
im fruhkindlichen Alter die Weichen fur das spatere Ernahrungs- und Bewegungsverhalten sowie die
Gesundheit im Erwachsenenalter gestellt.
... Babyschwimmen zählt zu den häufigen Bewegungsangeboten für Säuglinge. Hier wird der mögliche Nutzen gegenüber den erhöhten Risiken, insbesondere auch für Infektionen, kontrovers eingeschätzt [169,193]. [40,39]. ...
„Gesund ins Leben – Netzwerk Junge Familie“ ist ein Bestandteil von „IN FORM – Deutschlands Initiative für gesunde Ernährung und mehr Bewegung“ der Bundesregierung und wird durch das Bundesministerium für Ernährung und Landwirtschaft gefördert. In diesem bundesweiten Netzwerk haben sich medizinische und wissenschaftliche Fachgesellschaften, Berufsverbände sowie fachlich ausgerichtete Institutionen zusammengeschlossen, um Eltern rund um die Geburt mit Informationen zur Ernährung, zur Bewegung und zur Allergieprävention zu begleiten und zu unterstützen.
... Babyschwimmen zählt zu den häufigen Bewegungsangeboten für Säuglinge. Hier wird der mögliche Nutzen gegenüber den erhöhten Risiken, insbesondere auch für Infektionen, kontrovers eingeschätzt [169,193]. [40,39]. ...
Netzwerk„Gesund ins Leben – Netzwerk Junge Familie“ ist ein Bestandteil von „IN FORM – Deutschlands Initiative für gesunde Ernährung und mehr Bewegung“ der Bundesregierung und wird durch das Bundesministerium für Ernährung und Landwirtschaft gefördert. In diesem bundesweiten Netzwerk haben sich medizinische und wissenschaftliche Fachgesellschaften, Berufsverbände sowie fachlich ausgerichtete Institutionen zusammengeschlossen, um Eltern rund um die Geburt mit Informationen zur Ernährung, zur Bewegung und zur Allergieprävention zu begleiten und zu unterstützen. EmpfehlungenDie 2010 erstmals erschienenen Handlungsempfehlungen zu Säuglingsernährung und Ernährung der stillenden Mutter wurden auf Basis aktueller Empfehlungen relevanter Fachorganisationen und Institutionen sowie einschlägiger wissenschaftlicher Publikationen von den Mitgliedern des wissenschaftlichen Beirats des Netzwerks diskutiert, überarbeitet und im Konsens formuliert. Diese Empfehlungen werden zum einen als anwendungsorientierte, alltagsbezogene Botschaften an junge Familien weitergegeben, zum anderen in der Fortbildung der Multiplikatoren, ergänzt durch weiterführende Informationen, eingesetzt. Die Empfehlungen umfassen die Themen Stillen, Säuglingsnahrung, Beikost, Getränke (ergänzende Flüssigkeitszufuhr), Essenlernen, Ernährung der stillenden Frau, Nährstoffsupplemente für den Säugling und die stillende Mutter sowie Alkohol, Rauchen und Medikamente in der Stillzeit. Des Weiteren gehören allgemeine Empfehlungen zur Allergieprävention beim Kind sowie Empfehlungen zur Bewegung im Säuglingsalter und zur Bewegung der stillenden Frau dazu.
... This was supported by the association between the number of indoor chlorination swimming pools and prevalence of wheeze, asthma, hay fever, rhinitis, and atopic eczema in the European study centre, the International Study of Asthma and Allergies in Childhood [72]. Nevertheless, retrospectively collected information on 2606 adults showed no association between swimming pool attendance and asthma, although higher rates of hay fever could be seen in those who were frequently exposed at school age [73]. Also, a large population-based study showed that regular indoor swimming during infancy does not increase respiratory, allergic, or dermal symptoms in school children aged 6-12 years [74]. ...
Although training and exercise have several benefits, overdoing it might not necessarily be a good thing. For instance, elite athletes have an increased risk for asthma and allergy. Several mechanisms can be implicated for this risk, which include the interplay between environmental training factors and athlete's personal risk factors, such as genetic susceptibility, neurogenic-mediated inflammation, and epithelial sensitivity. However, an overwhelming amount of scientific evidence shows the positive effects of sports as part of a healthy lifestyle. Training reduces breathlessness and asthma symptoms and attenuates the mediated inflammatory responses. Taken together, the benefits far outweigh the potential hazards of training. An easily administered therapeutic healthy lifestyle intervention, which could be used alongside current treatment, must be developed.
... Various diseases including bacterial infections (i.e., skin, eye, ear, and respiratory infections, gastroenteritis, and granuloma), parasitic diseases (such as chronic diarrhea, cryptosporidiosis, and giardiasis), fungal infections (such as tinea and opportunistic mycosis), and viral diseases (such as hepatitis A, polio, and pharyngitis) may occur by using microbial-contaminated water (Silva et al. 2010). Several cases of these diseases, caused by swimming in polluted waters, have been reported (Philpott et al. 1963;Papadopoulou et al. 2008;Porter et al. 1988;Schoefer et al. 2008). Healthcare organizations suggest microbial indices for the microbial quality of swimming pools. ...
Microbial quality and physical-chemical properties of recreational spas were surveyed to investigate the health aspect of the spas' water. A total of 195 samples were collected from pools and springs of the spas in five sites from Ardebil Province of Iran. The effects of an independent factor defined as 'condition' and its component sub-factors (i.e., sampling point, location, and sampling date) on microbial quality and physical-chemical properties of the spas were studied by applying path analysis. The influence of physical-chemical properties on microbial quality was also considered. The percentage of samples exceeding the ISIRI (Swimming pool water microbiological specifications (vol 9412), Institute of Standards and Industrial Research of Iran, Tehran, 2007) limits for Staphylococcus (spp.) was up to 55.8 in the springs and 87.8 in the pools, 58.1 and 99.2 for HPC, 90.7 and 97.8 for total coliform and fecal coliform, and 9.3 and 34.4 for Pseudomonas aeruginosa, respectively. There were significant differences between the pools and springs for both physical-chemical properties and microbial quality. From the path analysis, sampling point was the most effective sub-factor of 'condition' on both the physical-chemical properties and microbial quality. Among the physical-chemical properties, water color had the most enhancing or additive influence on microbial pollution, while EC indicated a reducing or subtractive effect.
... Studies conducted in Belgium reported an increased risk of asthma among children with atopy that was associated with early indoor [87][88][89] and outdoor [90] swimming pool attendance. However, studies in other European countries such as Germany [91], Spain [92,93], the UK [94•], and the Netherlands [95], have found no association between swimming pool attendance and respiratory symptoms among children. Studies showing null associations were population-based and had larger sample sizes [91-93, 94•, 95]. ...
The presence of chemical compounds formed as disinfection by-products (DBPs) is widespread in developed countries, and virtually whole populations are exposed to these chemicals through ingestion, inhalation, or dermal absorption from drinking water and swimming pools. Epidemiological evidence has shown a consistent association between long-term exposure to trihalomethanes and the risk of bladder cancer, although the causal nature of the association is not conclusive. Evidence concerning other cancer sites is insufficient or mixed. Numerous studies have evaluated reproductive implications, including sperm quality, time to pregnancy, menstrual cycle, and pregnancy outcomes such as fetal loss, fetal growth, preterm delivery, and congenital malformation. The body of evidence suggests only minor effects from high exposure during pregnancy on fetal growth indices such as small for gestational age (SGA) at birth. Populations highly exposed to swimming pools such as pool workers and professional swimmers show a higher prevalence of respiratory symptoms and asthma, respectively, although the direction of the association, and thus causality, is not clear among professional swimmers. The risk of asthma, wheezing, eczema, and other respiratory outcomes among children attending swimming pools has been the object of extensive research. Early studies suggested a positive association, while subsequent larger studies found no correlations or showed a protective association. Future research should develop methods to evaluate the effects of the DBP mixture and the interaction with personal characteristics (e.g., genetics, lifestyle), clarify the association between swimming pools and respiratory health, evaluate the occurrence of DBPs in low- and middle-income countries, and evaluate outcomes suggested by animal studies that have not been considered in epidemiological investigations
... They explained that many of these incidents could be prevented through swimming exercises. Schoefer et al. (2008) explained that swimming pool attendance and exposure to chlorination byproducts demonstrated adverse health impacts on children. They investigated whether early swimming pool attendance, especially baby swimming, was associated with higher rates of early infections and to the development of allergic diseases. ...
Swimming is of the most important sports in the world and most countries try to find the most qualified people for participating in world's different championships. Training athletic people in swimming sport is more important in this area of sports compared with other sports. In this paper, we perform an empirical investigation to find the effects of various swimming sports on swimmers. The focus of this study is to compare the performance of two methods before and after two methods of interval and combined breast stroke swimming. The population of this survey includes all teenagers aged 13 and 14 who had, at least, one year of swimming experience. The sampling includes 30 people who were randomly selected and they were divided into two groups of 15 people. One group participated in interval training for three sessions per week and in an eight-week period. The second group took part in combined training for three sessions per week and in an eight-week period. At the end of training program, we have compared the results using t-student. Combined swimming includes different types of exercises. The results show that although there is a meaningful difference before and after two types of training programs but there is no different between the performances of these two tests.
Exercise‐induced bronchoconstriction (EIB) is exaggerated constriction of the airways usually soon after cessation of exercise. This is most often a response to airway dehydration in the presence of airway inflammation in a person with a responsive bronchial smooth muscle. Severity is related to water content of inspired air and level of ventilation achieved and sustained. Repetitive hyperpnea of dry air during training is associated with airway inflammatory changes and remodeling. A response during exercise that is related to pollution or allergen is considered EIB. Ozone and particulate matter are the most widespread pollutants of concern for the exercising population; chronic exposure can lead to new‐onset asthma and EIB. Freshly generated emissions particulate matter less than 100 nm is most harmful. Evidence for acute and long‐term effects from exercise while inhaling high levels of ozone and/or particulate matter exists. Much evidence supports a relationship between development of airway disorders and exercise in the chlorinated pool. Swimmers typically do not respond in the pool; however, a large percentage responds to a dry air exercise challenge. Studies support oxidative stress mediated pathology for pollutants and a more severe acute response occurs in the asthmatic. Winter sport athletes and swimmers have a higher prevalence of EIB, asthma and airway remodeling than other athletes and the general population. Because of fossil fuel powered ice resurfacers in ice rinks, ice rink athletes have shown high rates of EIB and asthma. For the athlete training in the urban environment, training during low traffic hours and in low traffic areas is suggested. © 2015 American Physiological Society. Compr Physiol 5:579‐610, 2015.
During the first year after the birth of a child, nutrition and physical activity are particularly important for the short and long-term health of both mother and child. The recommendations for action on nutrition and physical activity in infants and breastfeeding women are now partially updated and are intended to provide health professionals with a reliable basis for advising families with infants.
Based on recommendations from relevant specialist organizations and institutions as well as systematic reviews, meta-analyses, guidelines and other reliable study data, the scientific advisory board of the Healthy Start Network and other experts assessed the scientific evidence and formulated recommendations for action. A partial update took place in 2024. This concerns the recommendations for selecting infant formula when there is an increased risk of allergies, and for fluoride in the first year of life. All other recommendations reflect the status of 2016. Both processes were coordinated by the Healthy Start Network.
The recommendations for action cover the topics of breastfeeding, infant formula, complementary food, beverages or supplementary fluid intake, learning to eat, diet of breastfeeding women, nutritional supplements for infants and breastfeeding women as well as alcohol, smoking and medication during the lactation period. It also contains general recommendations on allergy prevention in children as well as recommendations on physical activity in infancy and for breastfeeding women.
Swimming is an excellent form of aerobic exercise and is an essential life skill. Many children with atopic dermatitis (AD) are advised not to swim because of concerns about negative impacts on their skin disease, and some children with AD do not swim because they are self-conscious about the appearance of their skin. We aimed to perform a narrative review of the available literature on swimming and AD and scientifically analyze the potential impact of all components of swimming in AD-water, skin barrier, swimming gear, and exercise. Studies examined the impact of swimming on the skin barrier and the relative contraindications to swimming. Constituents of water which may affect AD include hardness, pH, temperature, antiseptics, and other chemicals. Potential interventions to reduce damage included emollient application, special swim gear, and showering post-submersion. The benefits of swimming as a form of exercise in AD included reduced sweating, cardiorespiratory fitness, and maintenance of healthy weight. Drawbacks of swimming as a form of exercise in AD included the limited benefit on bone mineral density. Future research should examine the impact of swimming on flares of AD using noninvasive biomarkers as well as clinical severity assessment and assess the role for different types of emollient as an intervention for optimal eczema control. This review highlights gaps in the scientific literature on swimming and AD and provides evidence-based guidance on interventions to minimize deleterious effects on skincare and maximize opportunities for children with AD to swim.
Fresh water sanitation and disinfection using a variety of chemical entities as chlorination agents is an essential public health intervention ensuring water safety for populations at a global scale. Recently, we have published our observation that the small molecule oxidant, innate immune factor, and chlorination agent HOCl antagonizes inflammation and photocarcinogenesis in murine skin exposed topically to environmentally relevant concentrations of HOCl. Chlorinated isocyanuric acid derivatives [including the chloramines trichloroisocyanuric acid (TCIC) and dichloroisocyanuric acid (DCIC)] are used worldwide as alternate chlorination agents serving as HOCl‐precursor and stabilizer compounds ensuring sustained release in aqueous environments including public water systems, recreational pools, and residential hot tubs. Here, for the first time, we have examined the cutaneous TCIC‐induced transcriptional stress response (in both an organotypic epidermal model and in AP‐1 luciferase reporter SKH‐1 mouse skin), also examining molecular consequences of subsequent treatment with solar ultraviolet (UV) radiation. Taken together, our findings indicate that cutaneous delivery of TCIC significantly enhances UV‐induced inflammation (as profiled at the gene expression level), suggesting a heretofore unrecognized potential to exacerbate UV‐induced functional and structural cutaneous changes. These observations deserve further molecular investigations in the context of TCIC‐based freshwater disinfection with health implications for populations worldwide.
Hypochlorous acid (HOCl) water was first introduced in Japan in 1987, and its antibacterial properties were first reported in 1992. HOCl water is utilized to promote public health all over the world, and it has only lately begun to be used in agriculture and livestock production. It is usually produced by an electrolysis method. Low pH, high oxidation-reduction potential, high available chlorine concentration, and high dissolved oxygen concentration are all common properties of HOCl. Moreover, the property of HOCl water is affected by electrolysis factors such as concentrations of sodium chloride or hydrochloric acid as an additive, voltage, water flow velocity, and electric current. Recently, a mixing-type of HOCl disinfectant (Hydrogen Mineral Disinfectant, HMD) water has been developed and started to be used in agriculture and livestock farming due to numerous advantages such as high-concentration of chlorine, and large capacity of production, long-lasting storage, low level of harmful material, and easy handling. HMD has gained popularity as a disinfectant in agriculture, dentistry, medical, and the food business in recent years. It's been proved to be a good antibacterial for cutting boards. Numerous studies have shown that mixing-type disinfectant is more readily available than electrolyzed disinfectant for use in a variety of industries including pesticide-free organic farming, aquaculture, fish farming, cattle breeding, and food contact surfaces. Furthermore, drinking high concentration HOCl water (free active chlorine 50 ppm) is highly effective for preventing diarrheal disease, decreasing mortality, improving growth rate of broiler chickens and cows, and decreasing fecal stink and ammonia in the livestock breeding house. Therefore, in our current review we would like to introduce mixing type HMD, a new concept of disinfectant, and expand its usage in sustainable development in agriculture and livestock farming.
Concerns have been raised regarding the potential negative effects on human health of water disinfectants used in swimming pools. Among the disinfection options, the approaches using chlorine‐based products have been typically preferred. Chlorine readily reacts with natural organic matter that are introduced in the water mainly through the bathers, leading to the formation of potentially harmful chlorination by‐products (CBPs). The formation of CBPs is of particular concern since some have been epidemiologically associated with the development of various clinical manifestations. The higher the concentration of volatile CBPs in the water, the higher their concentration in the air above the pool, and different routes of exposure to chemicals in swimming pools (water ingestion, skin absorption, and inhalation) contribute to the individual exposome. Some CBPs may affect the respiratory and skin health of those who stay indoor for long periods, such as swimming instructors, pool staff, and competitive swimmers. Whether those who use chlorinated pools as customers, particularly children, may also be affected has been a matter of debate. In this article, we discuss the current evidence regarding the health effects of both acute and chronic exposures in different populations (work‐related exposures, intensive sports, and recreational attendance) and identify the main recommendations and unmet needs for research in this area.
Concerns have been raised regarding the potential negative effects on human health of water disinfectants used in swimming-pools. Among the disinfection options, the approaches using chlorine-based products have been typically preferred. Chlorine readily reacts with natural organic matter that are introduced in the water mainly through the bathers, leading to the formation of potentially harmful chlorination by-products (CBPs). The formation of CBPs is of particular concern since they have been epidemiologically associated with the development of various clinical manifestations. The higher the concentration of these volatile CBPs in the water, the higher their concentration in the air above the pool, and different routes of exposure to chemicals in swimming-pools (water ingestion, skin absorption and inhalation) contribute to the individual exposome. CBPs may affect the respiratory and skin health of those who stay indoor for long periods, such as swimming instructors, pool staff, and competitive swimmers. Whether those who use chlorinated-pools as customers, particularly children, may also be affected has been a matter of debate. In this article, the EAACI Joint Task Force of the Working Group of Allergy, Asthma & Sports and the Interest Groupf of Environmental & Occupational Allergy discusses the current evidence regarding the health effects of both acute and chronic exposures in different populations (work-related exposures, intensive sports and recreational attendance) and identify the main recommendations and unmet needs for research in this area.
A simple method for the collection and analysis of the four brominated and chlorinated trihalomethanes (THMs) in air samples is described. Ambient air samples were collected in pre‐prepared glass vials, with THM analysis performed using solid‐phase microextraction gas chromatography‐mass spectrometry, where the need for chemical reagents is minimised. Analytical parameters including oven temperature program, solvent volume, incubation time, vial agitation, extraction time and temperature, as well as desorption time and temperature, were evaluated to ensure optimal method performance. The developed method allows for point‐in‐time quantification (compared to an average concentration measured over extended periods of time), with detection limits between 0.7 to 2.6 μg/m³. Excellent linearity (r²>0.99), repeatability (3 to 11% RSD) and reproducibility (3 to 16% RSD) were demonstrated over a concentration range from 2 to 5000 μg/m³. The method was validated for the analysis of THMs in indoor swimming pool air and was used to investigate the occurrence of THMs in the air above fifteen indoor swimming pools. This is the first study to report the occurrence of THMs in swimming pool air in Australia and concentrations higher than those previously reported in other countries were measured.
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Drowning remains a significant public health concern, as it is a major cause of disability and death, particularly in children. Saved from drowning and loss of consciousness and subsequent water entering the respiratory is near-drowning that can lead to secondary drowning. So, the aim of this research is studying the effectual factors in Near-drowning in Qazvin swimming pools. This is a cross-sectional study. The study population included all licensed pools in Qazvin, 2016 by two-stage cluster sampling method. According to the results of the study, Near-drowning mostly occur in male, in child and adolescent age category and those with low education and insufficient swimming skill. The main reasons were lack of adequate skills in swimming and horseplay, and imprisonment of breath, fatigue and muscle cramps, respectively. Due to the high percentage of near-drowning in Qazvin swimming pools, it is essential that the authorities, a policy for swimming lessons more broadly, especially in the category of children and lifeguards prevent enter people with inadequate swimming skills in swimming, to the deep part of the pool and also horseplay in the pool should be avoided.
An association between airway dysfunction and airborne pollutant inhalation exists. Volatilized airborne fluorocarbons in ski wax rooms, particulate matter, and trichloromines in indoor environments are suspect to high prevalence of exercise-induced bronchoconstriction and new-onset asthma in athletes competing in cross-country skiing, ice rink sports, and swimming. Ozone is implicated in acute decreases in lung function and the development of new-onset asthma from exposure during exercise. Mechanisms and genetic links are proposed for pollution-related new-onset asthma. Oxidative stress from airborne pollutant inhalation is a common thread to progression of airway damage. Key pollutants and mechanisms for each are discussed.
Background
Knowledge development depends on an unbiased representation of the available evidence. Selective citation may distort this representation. Recently, some controversy emerged regarding the possible impact of swimming on childhood asthma, raising the question about the role of selective citation in this field. Our objective was to assess the occurrence and determinants of selective citation in scientific publications on the relationship between swimming in chlorinated pools and childhood asthma.
Methods
We identified scientific journal articles on this relationship via a systematic literature search. The following factors were taken into account: study outcome (authors’ conclusion, data-based conclusion), other content-related article characteristics (article type, sample size, research quality, specificity), content-unrelated article characteristics (language, publication title, funding source, number of authors, number of affiliations, number of references, journal impact factor), author characteristics (gender, country, affiliation), and citation characteristics (time to citation, authority, self-citation). To assess the impact of these factors on citation, we performed a series of univariate and adjusted random-effects logistic regressions, with potential citation path as unit of analysis.
Results
Thirty-six articles were identified in this network, consisting of 570 potential citation paths of which 191 (34%) were realized. There was strong evidence that articles with at least one author in common, cited each other more often than articles that had no common authors (odds ratio (OR) 5.2, 95% confidence interval (CI) 3.1–8.8). Similarly, the chance of being cited was higher for articles that were empirical rather than narrative (OR 4.2, CI 2.6–6.7), that reported a large sample size (OR 5.8, CI 2.9–11.6), and that were written by authors with a high authority within the network (OR 4.1, CI 2.1–8.0). Further, there was some evidence for citation bias: articles that confirmed the relation between swimming and asthma were cited more often (OR 1.8, CI 1.1–2.9), but this finding was not robust.
Conclusions
There is clear evidence of selective citation in this research field, but the evidence for citation bias is not very strong.
Electronic supplementary material
The online version of this article (doi:10.1186/s41073-017-0041-z) contains supplementary material, which is available to authorized users.
Background: Health of swimming pools is important to maintain health of swimmers that in case of failure to comply of health standards, can be lead to health problems and the transmission of infectious diseases to swimmers. The purpose of this study was to evaluate the water quality of swimming pools in Sanandaj city and compare of their results with the national standards. Methods: In this cross – sectional study, 108 water samples were collected from 9 swimming pools of Sanandaj city. Some parameters including residual chlorine, pH, turbidity, hardness, alkalinity, temperature and also microbial parameters such as heterotrophic bacteria, staphylococcus aureus, pseudomonas aeruginosa, fecal streptococcus, total coliform, and fecal coliform were evaluated. Results: The results of the study showed that residual chlorine, pH, turbidity, hardness, alkalinity, and temperature in 80.5%, 72.2%, 60.1%, 52.7%, 30.5%, and 100% of samples, respectively, which were in desirable limit. Also the population of total coliform, fecal coliform, and Staphylococcus aureus in 32.4%, 45.3%, and 96.3% of samples, respectively, were in desirable ranges. Conclusion: Based on the results, turbidity, hardness, alkalinity, and also population of total coliform and fecal coliform of some samples didn’t have conformity with standards that indicates the need for continuous monitoring of swimming pools water quality.
Disinfection of water for human use is essential to protect against microbial disease; however, disinfection also leads to formation of disinfection by-products (DBPs), some of which are of health concern. From a chemical perspective, swimming pools are a complex matrix, with continual addition of a wide range of natural and anthropogenic chemicals via filling waters, disinfectant addition, pharmaceuticals and personal care products and human body excretions. Natural organic matter, trace amounts of DBPs and chlorine or chloramines may be introduced by the filling water, which is commonly disinfected distributed drinking water. Chlorine and/or bromine is continually introduced via the addition of chemical disinfectants to the pool. Human body excretions (sweat, urine and saliva) and pharmaceuticals and personal care products (sunscreens, cosmetics, hair products and lotions) are introduced by swimmers. High addition of disinfectant leads to a high formation of DBPs from reaction of some of the chemicals with the disinfectant. Swimming pool air is also of concern as volatile DBPs partition into the air above the pool. The presence of bromine leads to the formation of a wide range of bromo- and bromo/chloro-DBPs, and Br-DBPs are more toxic than their chlorinated analogues. This is particularly important for seawater-filled pools or pools using a bromine-based disinfectant. This review summarises chemical contaminants and DBPs in swimming pool waters, as well as in the air above pools. Factors that have been found to affect DBP formation in pools are discussed. The impact of the swimming pool environment on human health is reviewed.
Background:
The association between asthma and swimming pool attendance has not been demonstrated and contrasting results emerged. In order to clarify the association between asthma diagnosis in children and swimming pool attendance, and to assess the consistency of findings of the available epidemiological studies, we completed a literature analysis focusing on literature about the relationship between the exposure to disinfection by-products in indoor swimming pool during childhood and asthma diagnosis.
Methods:
Following the MOOSE and PRISMA criteria, a systematic review and meta-analysis was performed by searching MEDLINE via PubMed, TOXNET, and Scopus databases (inception - April 20, 2015) using the key word "Asthma" together with "swimming pool", "disinfection by-products", "indoor air pollution" and "children". Inclusion criteria were: English language, a complete analytic study design comprising a cohort of children (0-16 years), a well-defined definition of exposure, and the presence of data on effect and variance. Studies considering in vivo, in vitro or professional and accidental exposures were excluded.
Results:
After a screening process, seven reports (n=5851 subjects) were included out of a total of 2928 references. The reported Odds Ratio (ORs) of the association between swimming pool attendance and asthma prevalence ranged from 0.58 to 2.30. The present meta-analysis failed to reveal a significant difference in asthma development between children attending swimming pools and controls (OR=1.084; 95%IC=0.89-1.31).
Conclusion:
Swimming in childhood does not increase the doctor diagnosed asthma. Based on this meta-analysis review, the association of the disease with attendance of indoor pools resulted inconsistent. Primary source of funding: This study was supported by IUSM grants 2014-2015. This article is protected by copyright. All rights reserved.
Transdermal therapeutic systems (TTS) have become a popular method of drug delivery because they allow drugs to be delivered in a rate-controlled manner, avoiding first-pass metabolism and the fluctuating plasma concentrations encountered with oral medications. Moreover, applying TTS is easy, does not require any assistance as intramuscular or intravenous administration, and provokes fewer side effects than there are with the oral delivery of drugs. Drugs most commonly delivered through TTS are scopolamine, estradiol, nitroglycerin, and clonidine. Unfortunately, TTS may provoke adverse skin reaction as irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). TTS seems to be ideally suited to produce sensitization because they cause occlusion, irritation, and repeated placement of the allergen at the same skin location. Since TTS consist of an adhesive, an active pharmaceutical drug and enhancing agents, sensitization may develop owing to one of these 3 components. The purpose of this manuscript is to review known responsible allergens of ACD to TTS. We describe also a case report about ACD to TTS caused by rivastigmine in a patient affected by Alzheimer's dementia. Rivastigmine is one of the latest drugs indicated as a known culprit allergen of ACD to TTS.
Background: atopic dermatitis (AD) is a chronic itchy inflammatory disease which affects up to 25% of children. AD is characterized by altered skin barrier and immunological dysfunctions. An athlete's skin is constantly exposed to a variety of stressors, both physical and environmental, which may affect the integrity of the skin barrier. Objective: the aim of this study is to evaluate the influence of sport activity on the course of AD and the influence of AD on the choice of sport type in a population of children and young adults. Materials and methods: in a cross-sectional case-control study 89 AD children and young adults ageing from 5 to 25 years (18.5 +/- 1.2) were compared to 196 age matched healthy individuals. All subjects practised sports. The patients were asked to fill in a survey which investigates the course of AD during sport activities. Results: AD was mild in 28 patients (31.5%), moderate in 45 (50.6%), and severe in 16 (17.9%). Thirty-four (38.2%) practised competitive sport and 61.8% non competitive sport. In the control group, sport activities were competitive in 71.9%, non competitive in 28.1%. AD patients practiced more than one sport in 33.7% of the cases, while in the control group 67.3% of the patients practiced multiple sport activities. Soccer was the predominant sport in both groups (39.3% cases vs 61.7% controls). Fifty-one patients (57.3%) referred skin related problems during sport activity, such as itch (57.3%), skin dryness (46.1%), eczema worsening (20.2%), intolerance to clothing (5.6%), allergic contact dermatitis to clothing (5.6%) and recurrent infections (3.4%). In the control group, only 7 patients (3.6%) had skin problems during sport activity, such as itch (3.1%), skin dryness (1%) and intolerance to clothing (0.5%). The type of sport activity practised did not differ in the 2 groups. Only a few patients affected by AD (3.4%) were influenced by the disease in the choice of sport activities. Conclusions: AD can be worsened by practice of sport. However, the disease does not represent a significant obstacle to competitive and not competitive physical exercise. None of our patients had to discontinue the sport because of skin adverse events. Sport activities can even be considered as adjuvant therapy improving the patient's mood and psychosocial well-being. Proper management of AD in addition to pharmacological treatment includes instructions to face environmental stressors that may affect the skin. It is however important to encourage young patients to practise sports.
Swimming is an activity enjoyed by people of all ages and abilities. With the notable health benefits and enjoyment associated with swimming, it is important that the water and facility do not become a source of disease and/or injury. Four factors contribute to maintaining healthy water quality in a recreational water facility: engineering design, water chemistry, disinfection and facility management. All factors must be operating properly for a facility to maintain a healthy bathing environment. This chapter will review the engineering design specifications that define the different facilities, discuss the importance of maintaining balanced water chemistry, provide an overview of the use and evaluation of recreational water disinfectants and end with a general discussion on the importance of well-trained facility managers. An overview of the various illnesses that are associated with recreational water that is not maintained will be presented as a cautionary note.
Exercise in children has important health benefits. However, in elite endurance athletes, there is an increased prevalence of exercise-induced bronchoconstriction and airway inflammation. Particularly at risk are those who practice in cold weather, ice rinks, swimming pools, and air pollution. The inflammation is caused by repetitive episodes of hyperventilation of cold, dry air, allergens, or toxins such as chlorine or air pollution. Children may be particularly at risk for lung injury under these conditions because of the immaturity and ongoing development of their lung. However, studies in pediatric athletes and exercising young children are sparse. Epithelial injury associated with hyperventilation of cold, dry air has not been described in children. However, exercise in the presence of air pollution and chlorine is associated with airway injury and the development of asthma in children; the effect appears to be modulated by both atopy and genetic polymorphisms. While management of exercise-induced bronchoconstriction and asthma is well established, there is little data to guide treatment or prevention of remodeling in athletes or inhalational lung injury in children. Studies underscore the need to maintain high levels of air quality. More investigations should be undertaken to better define the natural history, pathophysiology, and treatment of exercise-induced pulmonary inflammation in both elite athletes and exercising children.
Human exposure to chloride ions in swimming pools has been recognized as a potential health concern. Although environmental monitoring is a useful technique to investigate chloride ions 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. Consequently, the examination of chloride ions within swimming pool becomes an important test item for water quality control procedure. To effectively check the concentration of chloride ions in swimming pool, the evaluation process with an evaluation algorithm, indices of precision degree ( ), accuracy degree ( ) and the objective evaluation method with capability and concept of six sigma, proposed by Sung and Vännman are quoted in this paper to criticize examination tools for water quality in swimming pool. To ensure whether the evaluation method to measure chloride ion concentration in swimming pool holds precision, accuracy degrees and application functionality or not. The analysis results reveal that this method is suitable for examining the evaluation tool of chloride ions within swimming pool.
Childhood asthma is a complex condition where many environmental factors are implicated in causation. The aim of this study was to complete a systematic review of the literature describing associations between environmental exposures and the development of asthma in young children.
A systematic review of the literature up to November 2013 was conducted using key words agreed by the research team. Abstracts were screened and potentially eligible papers reviewed. Papers describing associations between exposures and exacerbation of pre-existing asthma were not included. Papers were placed into the following predefined categories: secondhand smoke (SHS), inhaled chemicals, damp housing/mould, inhaled allergens, air pollution, domestic combustion, dietary exposures, respiratory virus infection and medications.
Children aged up to 9 years.
Diagnosed asthma and wheeze.
14 691 abstracts were identified, 207 papers reviewed and 135 included in the present review of which 15 were systematic reviews, 6 were meta-analyses and 14 were intervention studies. There was consistent evidence linking exposures to SHS, inhaled chemicals, mould, ambient air pollutants, some deficiencies in maternal diet and respiratory viruses to an increased risk for asthma (OR typically increased by 1.5-2.0). There was less consistent evidence linking exposures to pets, breast feeding and infant dietary exposures to asthma risk, and although there were consistent associations between exposures to antibiotics and paracetamol in early life, these associations might reflect reverse causation. There was good evidence that exposures to house dust mites (in isolation) was not associated with asthma risk. Evidence from observational and intervention studies suggest that interactions between exposures were important to asthma causation, where the effect size was typically 1.5-3.0.
There are many publications reporting associations between environmental exposures and modest changes in risk for asthma in young children, and this review highlights the complex interactions between exposures that further increase risk.
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Background:
Asthma is a common condition characterised by airway inflammation and airway narrowing, which can result in intermittent symptoms of wheezing, coughing and chest tightness, possibly limiting activities of daily life. Water-based exercise is believed to offer benefits for people with asthma through pollen-free air, humidity and effects of exercise on physical function.
Objectives:
To evaluate the effectiveness and safety of water-based exercise for adults with asthma.
Search methods:
We searched the Cochrane Airways Group Specialised Register of Trials (CAGR), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED), PsycINFO, the Latin American and Caribbean Health Science Information Database (LILACS), the Physiotherapy Evidence Database (PEDro), the System for Information on Grey Literature in Europe (SIGLE) and Google Scholar on 13 May 2014. We handsearched ongoing clinical trial registers and meeting abstracts of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the British Thoracic Society (BTS).
Selection criteria:
We included all randomised controlled trials (RCTs) of adults with asthma comparing a water-based exercise group versus one or more of the following groups: usual care, land-based exercise, non-exercise.
Data collection and analysis:
Two review authors (AJG, VS) independently extracted data from the primary studies using a standard form developed for this purpose, which includes methods, participants, interventions and outcomes. We contacted trial authors to request additional data. Data were input by one review author and were double-checked by a second review author.
Main results:
In this systematic review, we provide a narrative synthesis of available evidence from three small studies including 136 adult participants. The studies were at high risk of bias. No meta-analysis was possible because of methodological and interventional heterogeneity between included studies. The primary outcomes of quality of life and exacerbations leading to use of steroids were not reported by these studies. For exacerbations leading to health centre/hospital visits, uncertainty was wide because a very small number of events was reported (in a single study). Secondary outcomes symptoms, lung function, changes in medication and adverse effects, where available, described for each included study. The overall quality of the studies was very low, and no clear differences were noted between water-based exercise and comparator treatments. Therefore, we remain very uncertain about the effects of water-based exercise for adults with asthma.
Authors' conclusions:
The small number of participants in the three included studies, the clinical and methodological heterogeneity observed and the high risk of bias assessed mean that we are unable to assess the place of water-based exercise in asthma. Randomised controlled trials are needed to assess the efficacy and safety of water-based exercise for adults with asthma. For future research, we suggest greater methodological rigour (participant selection, blinding of outcome assessors, reporting of all outcomes analysed and registering of the study protocol).
This study aimed to determine the health effects of attending a well-kept school swimming pool maintained according to French public health regulations.
This prospective month long study was carried out on a randomised sample of pupils aged 5 to 18 years who attended a private French school with two swimming pools. The children surveyed, helped by their parents, had to fill in questionnaires about their bathing habits and symptoms during the survey period. Inspections of the pool complex were made and these included physicochemical and bacteriological analyses of the pools' water. PARTICIPATION: The response rates achieved were 70% at primary and middle school levels but only 25% in the high school pupils. Because of this older teenagers were excluded from the final analysis (of 246 children).
Compared with non-bathers, bathers experienced fatigue and eye irritation significantly more often (p < 0.001). The eyes were red (38% of bathers) and/or watery (16%) after swimming but this resolved spontaneously within 24 hours. Bathing behaviour (bath duration, head immersion, wearing swimming goggles) did not affect these incidence rates noticeably. There were no differences between bathers and non-bathers with regard to other symptoms, especially otolaryngological ones. This survey does not allow definite conclusions to be made about verrucas because 22% of non-bathers were exempted from swimming because of verrucas that they might have caught previously in a pool.
Except for verrucas, the methodology was adequate and daily self reporting of symptoms was feasible. This college largely recruits pupils from higher social classes and is not therefore representative of schools in Paris.
To measure the levels of exposure to nitrogen trichloride (NCl3) in the atmosphere of indoor swimming pools and to examine how they relate to irritant and chronic respiratory symptoms, indices of pulmonary function, and bronchial hyperresponsiveness to methacholine in lifeguards working in the pools.
334 lifeguards (256 men; 78 women) recruited from 46 public swimming pools (n = 228) and 17 leisure centre swimming pools (n = 106) were examined. Concentrations of NCl3 were measured with area samplers. Symptoms were assessed by questionnaire and methacholine bronchial challenge (MBC) test by an abbreviated method. Subjects were labelled MBC+ if forced expiratory volume in one second (FEV1) fell by > or = 20%. The linear dose-response slope was calculated as the percentage fall in FEV1 at the last dose divided by the total dose given.
1262 samples were taken in the 63 pools. Mean NCl3 concentrations were greater in leisure than in public pools. A significant concentration-response relation was found between irritant eye, nasal, and throat symptoms-but not chronic respiratory symptoms-and exposure concentrations. Among women, the prevalence of MBC+ was twice as great as in men. Overall, no relation was found between bronchial hyperresponsiveness and exposure.
The data show that lifeguards exposed to NCl3 in indoor swimming pools are at risk of developing irritant eye, nasal, and throat symptoms. Exposure to NCl3 does not seem to carry the risk of developing permanent bronchial hyperresponsiveness, but this association might have been influenced by self selection. The possibility that subjects exposed to NCl3 are at risk of developing transient bronchial hyperresponsiveness cannot be confidently ruled out.
To study whether exposure to nitrogen trichloride in indoor chlorinated pools may affect the respiratory epithelium of children and increase the risk of some lung diseases such as asthma.
In 226 healthy children, serum surfactant associated proteins A and B (SP-A and SP-B), 16 kDa Clara cell protein (CC16), and IgE were measured. Lung specific proteins were measured in the serum of 16 children and 13 adults before and after exposure to NCl(3) in an indoor chlorinated pool. Relations between pool attendance and asthma prevalence were studied in 1881 children. Asthma was screened with the exercise induced bronchoconstriction test (EIB).
Pool attendance was the most consistent predictor of lung epithelium permeability. A positive dose-effect relation was found with cumulated pool attendance and serum SP-A and SP-B. Serum IgE was unrelated to pool attendance, but correlated positively with lung hyperpermeability as assessed by serum SP-B. Changes in serum levels of lung proteins were reproduced in children and adults attending an indoor pool. Serum SP-A and SP-B were already significantly increased after one hour on the pool side without swimming. Positive EIB and total asthma prevalence were significantly correlated with cumulated pool attendance indices.
Regular attendance at chlorinated pools by young children is associated with an exposure dependent increase in lung epithelium permeability and increase in the risk of developing asthma, especially in association with other risk factors. We therefore postulate that the increasing exposure of children to chlorination products in indoor pools might be an important cause of the rising incidence of childhood asthma and allergic diseases in industrialised countries. Further epidemiological studies should be undertaken to test this hypothesis.
It has been hypothesised that the rise in childhood asthma in the developed world could result at least in part from the increasing exposure of children to toxic chlorination products in the air of indoor swimming pools.
Ecological study to evaluate whether this hypothesis can explain the geographical variation in the prevalence of asthma and other atopic diseases in Europe.
The relationships between the prevalences of wheezing by written or video questionnaire, of ever asthma, hay fever, rhinitis, and atopic eczema as reported by the International Study of Asthma and Allergies in Childhood (ISAAC), and the number of indoor chlorinated swimming pools per inhabitant in the studied centres were examined. Associations with geoclimatic variables, the gross domestic product (GDP) per capita, and several other lifestyle indicators were also evaluated.
Among children aged 13-14 years, the prevalence of wheezing by written questionnaire, of wheezing by video questionnaire, and of ever asthma across Europe increased respectively by 3.39% (95% CI 1.96 to 4.81), 0.96% (95% CI 0.28 to 1.64), and 2.73% (95% CI 1.94 to 3.52), with an increase of one indoor chlorinated pool per 100 000 inhabitants. Similar increases were found when analysing separately centres in Western or Northern Europe and for ever asthma in Southern Europe. In children aged 6-7 years (33 centres), the prevalence of ever asthma also increased with swimming pool availability (1.47%; 95% CI 0.21 to 2.74). These consistent associations were not found with other atopic diseases and were independent of the influence of altitude, climate, and GDP per capita.
The prevalence of childhood asthma and availability of indoor swimming pools in Europe are linked through associations that are consistent with the hypothesis implicating pool chlorine in the rise of childhood asthma in industrialised countries.
The pool chlorine hypothesis postulates that the rise in childhood asthma in the developed world could result at least partly from the increasing exposure of children to toxic gases and aerosols contaminating the air of indoor chlorinated pools. To further assess this hypothesis, we explored the relationships between childhood asthma, atopy, and cumulated pool attendance (CPA). We studied 341 schoolchildren 10-13 years of age who attended at a variable rate the same public pool in Brussels (trichloramine in air, 0.3-0.5 mg/m3). Examination of the children included a questionnaire, an exercise-induced bronchoconstriction (EIB) test, and the measurement of exhaled nitric oxide (eNO) and total and aeroallergen-specific serum IgE. CPA by children (range, 0-1,818 hr) emerged among the most consistent predictors of asthma (doctor diagnosed or screened with the EIB test) and of elevated eNO, ranking immediately after atopy and family history of asthma or hay fever. Although the risk of elevated eNO increased with CPA [odds ratio (OR) = 1.30; 95% confidence interval (CI), 1.10-1.43] independently of total or specific serum IgE, the probability of developing asthma increased with CPA only in children with serum IgE > 100 kIU/L (OR for each 100-hr increase in CPA = 1.79; 95% CI, 1.07-2.72). All these effects were dose related and most strongly linked to pool attendance before 6-7 years of age. Use of indoor chlorinated pools especially by young children interacts with atopic status to promote the development of childhood asthma. These findings further support the hypothesis implicating pool chlorine in the rise of childhood asthma in industrialized countries.
Irritant gases and aerosols contaminating the air of indoor swimming pools can affect the lung epithelium and increase asthma risk in children. We evaluated the impact of infant swimming practice on allergic status and respiratory health later in childhood.
Clara cell protein, surfactant-associated protein D, and total and aeroallergen-specific immunoglobulin E were measured in the serum of 341 schoolchildren aged 10 to 13 years, among whom 43 had followed an infant swimming program. Asthma was defined as doctor-diagnosed asthma and/or positive exercise-induced bronchoconstriction (15% decrease in postexercise forced expiratory volume).
There were no significant differences between the infant swimming group and the other children regarding the levels of exhaled nitric oxide and total or aeroallergen-specific serum immunoglobulin E. Children who swam as infants showed, by contrast, a significant decrease of serum Clara cell protein and of the serum Clara cell protein/surfactant-associated protein D ratio integrating Clara cell damage and permeability changes of the lung epithelial barrier. These effects were associated with higher risks of asthma and of recurrent bronchitis. Passive exposure to tobacco alone had no effect on these outcomes but seemed to interact with infant swimming practice to increase the risk of asthma or of recurrent bronchitis.
Our data suggest that infant swimming practice in chlorinated indoor swimming pools is associated with airways changes that, along with other factors, seem to predispose children to the development of asthma and recurrent bronchitis.
Although chlorine and most of its derivates are known toxic agents, it has been pronounced as a safe disinfec-tant for water treatments. More detailed analyses and extended studies concerning chlorine safety have only started re-cently. The objective of this article was to review data on the use of chlorine in pool environments, the resulting chlorina-tion by-products in these environments and their potential effects on allergic and respiratory health in humans. The MEDLINE database search comprised articles from 1966 to August 2006. Additional studies were identified by searching references of already published articles. A total of twenty-one studies evaluating effects of chlorine and its by-products on allergic or respiratory health were included in the analysis. Exposure to chlorination by-products through swimming pool attendance showed adverse health effects on children, subjects occupationally exposed, athletic swimmers and asthmatic subjects. These adverse effects were seen despite the presence of official directives in most countries to control and regulate the use of chlorine for water disinfection. Contact to chlorination by-products might not be the lead-ing reason for poor respiratory health, but might not be as harmless as earlier thought. In particular, baby swimming in chlorinated pools is highly questionable.
Although pulmonary toxicity resulting from the inhalation of chlorine gas is well known in industrial accidents and warfare it may not be appreciated that adverse effects may result from bathing in chlorine-sterilised pools. The authors describe the sudden onset of reversible airways obstruction in three young swimmers.
Chlorine is used to disinfect swimming pools or as a constituent of other disinfection reagents. Pulmonary diseases are occasionally observed after exposure to chlorine. In 14 competitive swimmers and in 14 matched control subjects, we searched for clinically manifest allergies, subclinical sensitization to aeroallergens, imbalance of the cellular immune system, and bronchial hyperresponsiveness. Conjunctival or respiratory symptoms were found in 11 swimmers (2 cases of conjunctivitis, 4 rhinitis, 2 rhinoconjunctivitis, 1 laryngitis, and 2 bronchitis) and in 3 controls. Sensitization to aeroallergens was confirmed in 9 swimmers by skin test and in 11 swimmers by radioallergosorbent test (RAST), compared to findings in 4 and 5 controls, respectively. An altered cellular immune system, (i.e., imbalance in T-cell system, B-cell system, or natural killer cells) was detected in 7 swimmers and only 2 controls. Bronchial hyperresponsiveness to methacholine was seen in 11 swimmers and 5 controls. This higher incidence of allergic diseases and subclinical sensitization to aeroallergens, disorders of the cellular immune system, and bronchial hyperresponsiveness in competitive swimmers compared with control subjects could be due to repeated exposure to chlorine in swimming pools.
Ten swimmers had rhinomanometry, mucociliary clearance time and lung function tests performed pre and post swimming in a chlorinated swimming pool. No evidence of nasal irritation or adverse effects on nasal function were obtained.
An epidemiological study involving 893 people was undertaken during the 1980/81 summer period in the Richmond and Windsor region of New South Wales to determine the incidence of swimmers and non-swimmers reporting ear, eye, skin, throat and gastrointestinal complaints. Swimmers were found to report a greater incidence of ear and eye complaints than non-swimmers. Swimmers who swam in community pools were found to have a significantly higher incidence of earache compared to other swimmers. The findings of the study supported overseas work which suggests that the incidence of earache among swimmers may be a useful health indicator in the evaluation of waters for recreational use.
To investigate respiratory symptoms, increased bronchial responsiveness, and signs of airway inflammation in elite swimmers, we examined 29 swimmers from the Finnish national team and 19 healthy control subjects (nonasthmatic, symptom-free). They answered a questionnaire and were interviewed for respiratory symptoms. Lung volumes were measured and bronchial responsiveness assessed by a histamine challenge test. Induced sputum samples were also collected. Fourteen (48%) of the swimmers and three (16%) of the control subjects showed increased bronchial responsiveness (P<0.05). The sputum cell differential counts of eosinophils (mean 2.7% vs 0.2%) and neutrophils (54.7% vs 29.9%) from swimmers were significantly higher than those from controls (P<0.01). Eosinophilia (sputum differential eosinophil count of >4%) was observed in six (21%) of the swimmers and in none of the controls (P<0.05). Symptomatic swimmers had significantly more sputum eosinophils than did the symptom-free. The concentrations of sputum eosinophil peroxidase (EPO) and human neutrophil lipocalin (HNL) were significantly higher in swimmers than control subjects (P<0.001 and P=0.05). We conclude that elite swimmers had significantly more often increased bronchial responsiveness than control subjects. Sputum from swimmers contained a higher percentage of eosinophils and neutrophils, and higher concentrations of EPO and HNL than sputum from controls. Long-term and repeated exposure to chlorine compounds in swimming pools during training and competition may contribute to the increased occurrence of bronchial hyperresponsiveness and airway inflammation in swimmers.
The first series of three workers who developed occupational asthma following exposure to airborne chloramines in indoor chlorinated swimming pools is reported. Health problems of swimmers in indoor pools have traditionally been attributed to the chlorine in the water. Chlorine reacts with bodily proteins to form chloramines; the most volatile and prevalent in the air above swimming pools is nitrogen trichloride.
Two lifeguards and one swimming teacher with symptoms suggestive of occupational asthma kept 2-hourly measurements of peak expiratory flow at home and at work, analysed using the occupational asthma system (OASYS) plotter, and/or had specific bronchial challenge testing to nitrogen trichloride, or a workplace challenge.
Air measurement in one of the pools showed the nitrogen trichloride levels to be 0.1−0.57 mg·m ⁻³ , which was similar to other studies. Two workers had peak expiratory flow measurements showing occupational asthma (OASYS-2 scores 2.88 and 3.8), both had a positive specific challenge to nitrogen trichloride at 0.5 mg·m ⁻³ with negative challenges to chlorine released from sodium hypochlorite. The third worker had a positive workplace challenge.
Swimming-pool asthma due to airborne nitrogen trichloride can occur in workers who do not enter the water because of this chloramine. The air above indoor swimming pools therefore needs to be assessed and managed as carefully as the water.
Mild eosinophilic airway inflammation and bronchial hyperresponsiveness-ie, mild asthma-have been shown to affect a high proportion of endurance athletes. The persistence of airway inflammation, bronchial hyperresponsiveness, and asthma in this population is not known, however, inasmuch as follow-up studies of athletes' asthma have not been performed.
The purpose of this study was to investigate effect of finishing high-level sports on airway inflammation, bronchial hyperresponsiveness, and asthma.
Forty-two elite competitive swimmers, most of them from the Finnish national team (37/42; 88%), were followed for 5 years in a prospective manner. All of the swimmers completed questionnaires and underwent resting spirometry, histamine challenge testing, and skin prick tests at baseline and at follow-up. Twenty-nine swimmers (69%) also gave induced sputum samples on both occasions. Sixteen (38%) of the swimmers had continued their competitive careers during follow-up (active swimmers), but 26 (62%) had stopped competing more than 3 months before the follow-up examination (past swimmers).
Bronchial responsiveness was increased in 7 (44%) of the 16 active swimmers at baseline and in 8 (50%) of the 16 active swimmers at follow-up; it was increased in 8 (31%) of the 26 past swimmers at baseline and in 3 (12%) of the 26 past swimmers at follow-up (McNemar test, P =.025). The difference in the change in bronchial hyperresponsiveness between the study groups was significant (likelihood ratio test, P =.023). Current asthma (defined as bronchial hyperresponsiveness and exercise-induced bronchial symptoms monthly) was observed in 5 (31%) of the active swimmers at baseline and in 7 (44%) of the active swimmers at follow-up; of the past swimmers, it occurred in 6 (23%) at baseline and in 1 (4%) at follow-up (McNemar test, P =.025). The difference in the change in current asthma between the study groups was significant (likelihood ratio test, P =.0040). The sputum differential cell counts of eosinophils and lymphocytes increased significantly during the follow-up period in the active swimmers (Wilcoxon signed rank sum test; P =.033 and P =.0029, respectively); in the past swimmers, the sputum differential cell counts of eosinophils tended to decrease during the follow-up period (P =.17), whereas the differential cell counts of lymphocytes did not change significantly. The changes in the sputum differential cell counts of eosinophils between the study groups differed significantly (Mann-Whitney U test, P =.019).
In swimmers who had stopped high-level training, bronchial hyperresponsiveness and asthma attenuated or even disappeared. Mild eosinophilic airway inflammation was aggravated among highly trained swimmers who remained active during the 5-year follow-up. Our results suggest that athletes' asthma is partly reversible and that it may develop during and subside after an active sports career.
Nitrogen trichloride (NCl(3)) is an irritant gas released in the air of indoor pools sanitized with chlorine-based disinfectants. In the present study we investigated the effects of NCl(3) on the pulmonary epithelium of pool attendees by measuring the leakage into serum of three lung-specific proteins (pneumoproteins): the alveolar surfactant-associated proteins A and B (SP-A and SP-B) and the bronchiolar 16 kDa Clara cell protein (CC16). These pneumoproteins were measured in the serum of 29 recreational swimmers (16 children and 13 adults) before and after attending a chlorinated pool with a mean NCl(3) concentration of 490 microg m(-3). Pneumoprotein changes in serum were also studied in 14 trained swimmers performing an intensive 45 min standardized swimming session in a chlorinated pool (mean NCl(3) concentration of 355 microg m(-3)) and for the purposes of comparison in a non-chlorinated pool sanitized by the copper/silver method. Serum CC16 was not increased in recreational swimmers, but in trained swimmers serum levels of this protein peaked immediately after strenuous exercise, both in the copper/silver pool and in the chlorinated pool. This acute increase in airway permeability is probably the consequence of the mechanical stress on the epithelial barrier caused by overinflation and/or hyperventilation during intense exercise. Serum levels of SP-A and SP-B were unaffected by strenuous exercise in the copper/silver pool. The two proteins were, however, significantly increased in a time-dependent manner in recreational and trained swimmers attending the chlorinated pool. The intravascular leakage of SP-A and SP-B was already statistically significant after only 1 h of exposure to pool air without exercising and remained elevated for 12 h after. These changes were not associated with decrements in lung function. The ability of NCl(3) to acutely disrupt the lung epithelium barrier was confirmed in mice using serum CC16 and plasma proteins in bronchoalveolar lavage fluid as permeability markers. The significance of these permeability changes induced by NCl(3) in the deep lung is presently unknown. In view of the increasing and widespread human exposure to this gas not only in indoor pools but also in a variety of other situations, these findings warrant further study.
Some patients with atopic dermatitis (AD) develop dry skin or exacerbated cutaneous inflammations with frequent swimming in public pools or after bathing. We examined the effects of residual chlorine in bathing water on the function of the stratum corneum (SC) in patients with AD and determined the lowest chlorine concentration showing an effect. In addition, we investigated the relationship between the free residual chlorine concentration in bathing water and the water-holding capacity of the SC in patients with AD. Twenty patients with AD and 10 normal control (NC) subjects were included in this study. The hydration status of the SC on the flexor surface of the forearm was measured with a corneometer before and after the subject's arms were immersed in tubs filled with comfortably hot water (40 degrees C) containing residual chlorine at concentrations of 0, 0.5, 1.0 and 2.0 mg/L for 10 minutes in a room maintained at normal temperature (24 degrees C) and relative humidity (55%). The water-holding capacity of the SC after immersion was calculated by integration of the hydration status determined every 30 seconds over a period of 10 minutes. In the patients with AD, the average SC hydration status after immersion in comfortably hot water containing residual chlorine at 1.0 and 2.0 mg/L was significantly lower than that following immersion in water containing a negligible concentration of residual chlorine (i.e., less than 0.03 mg/L) (p<0.05). In the NC subjects, significant differences were observed only between the 2.0 mg/L and the negligible residual chlorine groups (p<0.05). The water-holding capacity of the SC was significantly decreased with a residual chlorine concentration of 0.5 mg/L or higher in the patients with AD (p<0.01). However, in the NC subjects, a significant decrease in water-holding capacity was observed only at a residual chlorine concentration of 2 mg/L (p<0.01). These results indicate, first, that the water-holding capacity of the SC in patients with AD is more sensitive to free residual chlorine exposure than that in NC subjects without AD. Second, these results suggest that free residual chlorine exposure in patients with AD may play a role in the development or exacerbation of AD.
Seasonal allergic rhinitic (SAR) subjects are more sensitive to nasal irritants than nonrhinitic (NR) subjects; however, the mechanism underlying this difference is unclear. This study sought to determine whether irritant-induced nasal congestion involves mast cell degranulation.
Eight SAR and eight NR subjects were exposed to both 1.0 parts per million chlorine and filtered air in separate visits; exposures were via nasal mask and lasted 15 min. Rhinomanometry was performed before, immediately after and 15 min after exposure. Following ≥2 weeks, exposures and symptom reporting were repeated with nasal lavage, rather than rhinomanometry, pre- and postexposure. A separate substudy using rye grass antigen provided a positive control. Mast cell tryptase was measured in nasal lavage fluid from both substudies using an automated fluoroenzyme immunoassay.
Chlorine provocation significantly increased nasal airway resistance in SAR but not NR subjects. Conversely, tryptase levels in nasal lavage fluid were unaffected. Nasal allergen challenge significantly increased both nasal obstruction and nasal lavage tryptase in SAR subjects.
Irritant-induced nasal congestion is more pronounced among seasonal allergic rhinitic than nonrhinitic subjects. However, unlike nasal allergen challenge, the mechanism of response to chlorine does not appear to involve mast cell degranulation.
To estimate the association between baby swimming and recurrent respiratory tract infections and otitis media in the first year of life in children of parents without and with atopy.
Norwegian schoolchildren (n = 2862) was enrolled in a cross-sectional study of asthma and allergy using the questionnaire of the International Study of Asthma and Allergies in Childhood (ISAAC). The outcomes were parental retrospective report of recurrent respiratory tract infections and otitis media diagnosed by a physician in the first year of life. The exposure was baby swimming during the same period. Parental atopy reflects a history of maternal or paternal asthma, hayfever or eczema.
The prevalence of recurrent respiratory tract infections was higher (12.3%) among children who took part in baby swimming than among those who did not (7.5%). The prevalence of recurrent respiratory tract infections during the first year of life was 5.6% and 10.5%, respectively, in children of parents without and with atopy, whereas the prevalence of baby swimming was 5.6% and 5.1%, respectively, in the two groups. Stratified analysis using parental atopy as strata showed that the increased risk of recurrent respiratory tract infections was only present among children of parents with atopy [adjusted odds ratio (aOR) 2.08, 95% confidence interval (95% CI) 1.08-4.031. A similar trend was present for otitis media (aOR 1.77, 95% CI 0.96-3.25).
The results of this study suggest that baby swimming and infant respiratory health may be linked. The findings need to be examined in a longitudinal study.
To the Editor: Public baths and swimming pools need to be disinfected, and this is usually accomplished by chlorination of the water. Exposure to chlorinated pools, however, may affect the lung epithelium and, along with other factors, may be associated with the increased prevalence of childhood asthma.1 In addition, the chloramines,2,3 which are generated from the reaction of hypochlorite with ammonia and amino compounds that originate from sweat and urine, are substances that are highly volatile and irritating to the airways. The magnitude of exposure to these substances depends on the number of bathers, the water temperature, and local . . .
Exposure to chlorination by-products through swimming pool attendance showed adverse health effects on children. The aim of our study was to assess whether pool attendance in childhood would be related to higher rates of allergic diseases in adulthood, with special regard to hay fever.
2606 adults aged 35-74 years provided retrospectively collected information on swimming pool attendance and medical history, including data on atopic diseases. Information was assessed by a combination of a personal interview and a self-administered questionnaire. Logistic regression models were applied to study associations between hay fever and swimming pool attendance, adjusted for potentially relevant confounders, such as age, gender, region, education and smoking.
Higher rates of hay fever could be seen when frequently exposed at school age (aOR: 1.74, 95% CI: 1.09-2.77), frequently exposed during the past 12 months (aOR: 1.32, 95% CI: 0.92-1.89) and ever exposed (aOR: 1.65, 95% CI: 0.98-2.78). Strongest associations were found for the youngest subjects and were dose-related to the extent of current and school-age pool attendance.
Impaired integrity of the lung epithelial by exposure to chlorination by-products might facilitate a closer contact to allergens and therefore could result in higher rates of hay fever.
Relations between exposure to chlorinated compounds and biological markers of response to oxidative stimuli were investigated in swimmers, taking into account the effect of training. Twenty-two male swimmers aged 15-25 years were surveyed twice. Prevalence of irritant symptoms and asthma and number of hours of training were reported. Exposure to nitrogen trichloride (NCl3) and blood response to oxidative stimuli [catalase, superoxide dismutase (Cu2+/Zn2+ SOD), glutathione peroxidase (GSH-Px) activities and ceruloplasmin, ferritin and total antioxidant concentrations] were measured. Univariate analyses were completed by multivariate analyses. High prevalences of irritant symptoms and asthma were found. Multivariate analysis confirmed the results of the univariate analyses and showed that Cu2+/Zn2+ SOD activity was increased by exposure and by training (P = 0.01, P = 0.0001, respectively). Erythrocyte GSH-Px was decreased, whereas plasma GSH-Px was increased by exposure (P = 0.002, P = 0.002). No other association was found. Higher irritant symptoms and increases in the activities of erythrocyte Cu2+/Zn2+ SOD and of plasma GSH-Px with exposure support the hypothesis that the production of reactive oxygen species is not only related to training but also to exposure to chlorinated compounds. Other athletes tend to have respiratory problems such as asthma, but the exposure to chlorinated compounds may increase the respiratory disease among swimmers.
Swimming programs for infants and toddlers. Committee on Sports Medicine and Fitness and Committee on Injury and Poison Prevention
American Academy of Pediatrics, 2000. Swimming programs
for infants and toddlers. Committee on Sports Medicine
and Fitness and Committee on Injury and Poison Prevention. Pediatrics 105, 868-870.
Surveillance data from swimming pool inspections-selected states and counties, United States, MaySeptember
MMWR, 2003. Surveillance data from swimming pool inspections-selected states and counties, United States, MaySeptember 2002. Morb. Mortal. Wkly. Rep. 52, 513-516.
Baby swimming increases the risk of recurrent respiratory tract infections and otitis media
- Nystad
Effect of continuing or finishing high-level sports on airway inflammation, bronchial hyperresponsiveness, and asthma: a 5-year prospective follow-up study of 42 highly trained swimmers
- Helenius