A Review of Chlorine in Indoor Swimming Pools and its Increased Risk of Adverse Health Effects
DOI:
https://doi.org/10.18192/riss-ijhs.v2i1.1526Keywords:
Chlorine, adverse health effects, indoor swimming poolsAbstract
Background: Chlorine is a commonly used agent for water disinfectant in swimming pools. Inadequate ventilation in indoor swimming pools and chlorination disinfectant by-products (DBP’s) caused by organic matter promote the increased risk of adverse health effects. Water quality and proper ventilation must be monitored to avoid health risks in youth and adolescents.
Methods: Studies were researched on children and adolescents from 2-18 years old who swim indoors. Articles were limited by only including journals from the year 2000 through 2010 and contain global statistics. Peer reviewed scientific articles were reviewed and a meta-analysis of three different scientific research databases, PubMed, Web of Science and Google Scholar, was conducted.
Results and Conclusions: Children under five years of age, lifeguards and elite swimmers are at an increased risk of upper and lower respiratory symptoms, such as asthma, when exposed to chlorinated swimming frequently. Recreational swimmers who swim moderately are at a lower risk for developing occupational asthma.
Implications: Reducing exposure to chlorine from indoor swimming pools may limit the risk of developing upper and lower respiratory infections.
References
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Bougault, V., Turmel, J., Levesque, B., & Boulet, L. P. (2009). The respiratory health of swimmers. Sports Medicine, 39(4), 295-312. doi: 10.2165/00007256-200939040- 00003
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Carbonnelle, S., Francaux, M., Doyle, I., Dumont, X., de Burbure, C., Morel, G., ... & Bernard, A. (2002). Changes in serum pneumoproteins caused by short-term exposures to nitrogen trichloride in indoor chlorinated swimming pools. Biomarkers, 7(6),464-478. doi: 10.1080/13547500210166612
Carraro, S., Pasquale, M. F., Da Fre, M., Rusconi, F., Bonetto, G., Zanconato, S., & Baraldi, E. (2006). Swimming pool attendance and exhaled nitric oxide in children. The Journal of Allergy and Clinical Immunology, 118(4), 958- 960. doi: 10.1016/j.jaci.2006.07.016
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Font-Ribera, L., Kogevinas, M., Zock, J. P., Nieu- wenhuijsen, M. J., Heederik, D., & Villanueva, C. M. (2009). Swimming pool attendance and risk of asthma and allergic symptoms in children. The European Respiratory Journal, 34(6), 1304-1310. doi: 10.1183/09031936.00180608
Health Canada. (2009). Swimming pool and spa sanitation. Retrieved from http://publications.gc.ca/collections/Collection/H113-1-24-1999E.pdf
Ishioka, M., Kato, N., Kobayashi, A., Dogru, M., & Tsubota, K. (2008). Deleterious effects of swimming pool chlorine on the corneal epithelium. Cornea, 27(1), 40-43. doi: 10.1097/ICO.0b013e318156d20
Life Saving Society. (2004). Public wading pool safety standards. Retrieved from http://www.lifesaving.org/download/PublicWadingPoolSafetyStandards.pdf
Lourencetti, C., Fernández, P., Marco, E., Ballesté, C., Grimalt, J. O., Font, L., ... & Kogevinas, M. (2008). Trihalomethane levels in exhaled breath as indicators of exposure to disinfection by-products in indoor swimming pools using chlorine and bromine as disinfectants. Epidemiology, 19(6), 191-192. doi: 10.1097/01.ede.0000340079.17087.fc
McGrath, P. (Ed.). (2004). Guidelines for swimming pools: Province of Nova Scotia. Department of Labour and Environment. **Editor’s note: this reference (1987 Department of Health Public Swimming Pool Guidelines) was retired by the Department in late 2011 because there were sections that were scientifically out of date.
Nemery, B., Hoet, P. H., & Nowak, D. (2002). Indoor swimming pools, water chlorination and respiratory health. European Respiratory Journal, 19(5), 790-793. doi: 10.1183/09031936.02.00308602
Nickmilder, M., & Bernard, A. (2007). Ecological association between childhood asthma and availability of indoor chlorinated swimming pools in Europe. Occupational and Environmental Medicine, 64(1), 37-46. doi: 10.1136/oem.2005.025452
Nieuwenhuijsen, M. J. (2007). The chorine hypothesis: Fact or fiction? Occupational and Environmental Medicine, 64(1), 6-7. doi: 10.1136/oem.2006.029850
Spivey, A. (2006). Swimming in allergens: Pool use and asthma. Environmental Health Perspectives, 114(10), A600. Retrieved from http://ehp.niehs.nih.gov/
Thomas, L., & Murray, V. (2008). Review of acute chemical incidents involving exposure to chlorine associated with swimming pools in England and Wales, June-October 2007. Journal of Public Health, 30(4), 391-397. doi: 10.1093/pubmed/fdn073
Uyan, Z. S., Carraro, S., Piacentini, G., & Baraldi, E. (2009). Swimming pool, respiratory health, and childhood asthma: Should we change our beliefs? Pediatric Pulmonology, 44(1), 31-37. doi: 10.1002/ppul.20947
Villanueva, C. M., Font-Ribera, L., Gómez, F. P., Barreiro, E., Zock, J., Nieuwenhuijsen, M. J.,...Kogevinas, M. (2008). Acute exposure to disinfection by-products in swimming pools and short term changes in respiratory biomarkers [Abstract]. Epidemiology, 19(6), S107 doi: 10.1097/01.ede.0000339853.71572.70
Voisin, C., & Bernard, A. (2008). Risks of allergic reactions to chlorination byproducts in swimming pools. Environnement Risques & Santé, 7(6), 417-423. doi: 10.1684/ers.2008.0181
Wattigney, W. A., Kaye, W. E., & Orr, M. F. (2007). Acute hazardous substance releases resulting in adverse health consequences in children: Hazardous substances emergency events surveillance system, 1996-2003. Journal of Environmental Health, 70(4), 17-24. Retrieved from http:// www.neha.org/JEH/
Weaver, W. A., Li, J., Wen, Y., Johnston, J., Blatchley, M. R., & Blatchley, E. R., III. (2009). Volatile disinfection by-product analysis from chlorinated indoor swimming pools. Water Research, 43(13),3308-3318. doi: 10.1016/ j.watres.2009.04.035
Weisel, C. P., Richardson, S. D., Nemery, B., Aggazzotti, G., Baraldi, E., Blatchley, E. R., III, ... & Sattar, S. (2009). Childhood asthma and environmental exposures at swimming pools: State of the science and research recommendations. Environmental Health Perspectives, 117(4), 500- 507. doi: 10.1289/ehp.11513
World Health Organization. (2006). Guidelines for safe recreational water environments. Volume 2: Swimming pools and similar environments. Retrieved from http://apps.who.int/iris/bitstream/10665/43336/1/9241546808_eng.pdf?ua=1
Zwiener, C., Richardson, S. D., DeMarini, D. M., Grummt, T., Glauner, T., & Frimmel, F. H. (2007). Drowning in disinfection by products? Assessing swimming pool water. Environmental Science & Technology, 41(2), 363-372. doi: 10.1021/es062367v
Bernard, A., Carbonnelle, S., de Burbure, C., Michel, O., & Nickmilder, M. (2006). Chlorinated pool attendance, atopy, and the risk of asthma during childhood. Environmental Health Perspectives, 114(10),1567- 1573. Retrieved from http://ehp.niehs.nih.gov/
Bernard, A., Carbonnelle, S., Dumont, X., & Nickmilder, M. (2007). Infant swimming practice, pulmonary epithelium integrity, and the risk of allergic and respiratory diseases later in childhood. Pediatrics, 119(6). 1095-1103. doi: 10.1542/peds.2006-3333
Bernard, A., Nickmilder, M., & Voisin, C. (2008). Outdoor swimming pools and the risks of asthma and allergies during adolescence. The European Respiratory Journal, 32(4), 979-988. doi: 10.1183/09031936.00114807
Bernard, A., Nickmilder, M., Voisin, C., & Sardella, A. (2009). Impact of chlorinated swimming pool attendance on the respiratory health of adolescents. Pediatrics, 124 (4), 1110-1118. doi: 10.1542/peds.2009-0032
Bougault, V., Turmel, J., Levesque, B., & Boulet, L. P. (2009). The respiratory health of swimmers. Sports Medicine, 39(4), 295-312. doi: 10.2165/00007256-200939040- 00003
Canadian Center for Occupational Health and Safety. (2003). Working safely with chlorine. Retrieved from http://www.ccohs.ca/oshanswers/chemicals/chem_profiles/chlorine.html
Carbonnelle, S., Francaux, M., Doyle, I., Dumont, X., de Burbure, C., Morel, G., ... & Bernard, A. (2002). Changes in serum pneumoproteins caused by short-term exposures to nitrogen trichloride in indoor chlorinated swimming pools. Biomarkers, 7(6),464-478. doi: 10.1080/13547500210166612
Carraro, S., Pasquale, M. F., Da Fre, M., Rusconi, F., Bonetto, G., Zanconato, S., & Baraldi, E. (2006). Swimming pool attendance and exhaled nitric oxide in children. The Journal of Allergy and Clinical Immunology, 118(4), 958- 960. doi: 10.1016/j.jaci.2006.07.016
Centers for Disease Control and Prevention. (2010a). Violations identified from routine swimming pool inspections—selected states and counties, United States, 2008. Morbidity and Mortality Weekly Report, 59(19), 582-587. Retrieved from http://www.cdc.gov/mmwr/
Centers for Disease Control and Prevention. (2010b). Your disinfection team: Chlorine & pH. Retrieved from http://www.cdc.gov/healthywater/pdf/swimming/resources/ disinfection-team-chlorine-phfactsheet.pdf
Eggleston, P. A. (2007). Chlorinated pools and the risk of asthma. Environmental Health Perspectives, 115(5), A240- A241; author reply.
Font-Ribera, L., Kogevinas, M., Zock, J. P., Nieu- wenhuijsen, M. J., Heederik, D., & Villanueva, C. M. (2009). Swimming pool attendance and risk of asthma and allergic symptoms in children. The European Respiratory Journal, 34(6), 1304-1310. doi: 10.1183/09031936.00180608
Health Canada. (2009). Swimming pool and spa sanitation. Retrieved from http://publications.gc.ca/collections/Collection/H113-1-24-1999E.pdf
Ishioka, M., Kato, N., Kobayashi, A., Dogru, M., & Tsubota, K. (2008). Deleterious effects of swimming pool chlorine on the corneal epithelium. Cornea, 27(1), 40-43. doi: 10.1097/ICO.0b013e318156d20
Life Saving Society. (2004). Public wading pool safety standards. Retrieved from http://www.lifesaving.org/download/PublicWadingPoolSafetyStandards.pdf
Lourencetti, C., Fernández, P., Marco, E., Ballesté, C., Grimalt, J. O., Font, L., ... & Kogevinas, M. (2008). Trihalomethane levels in exhaled breath as indicators of exposure to disinfection by-products in indoor swimming pools using chlorine and bromine as disinfectants. Epidemiology, 19(6), 191-192. doi: 10.1097/01.ede.0000340079.17087.fc
McGrath, P. (Ed.). (2004). Guidelines for swimming pools: Province of Nova Scotia. Department of Labour and Environment. **Editor’s note: this reference (1987 Department of Health Public Swimming Pool Guidelines) was retired by the Department in late 2011 because there were sections that were scientifically out of date.
Nemery, B., Hoet, P. H., & Nowak, D. (2002). Indoor swimming pools, water chlorination and respiratory health. European Respiratory Journal, 19(5), 790-793. doi: 10.1183/09031936.02.00308602
Nickmilder, M., & Bernard, A. (2007). Ecological association between childhood asthma and availability of indoor chlorinated swimming pools in Europe. Occupational and Environmental Medicine, 64(1), 37-46. doi: 10.1136/oem.2005.025452
Nieuwenhuijsen, M. J. (2007). The chorine hypothesis: Fact or fiction? Occupational and Environmental Medicine, 64(1), 6-7. doi: 10.1136/oem.2006.029850
Spivey, A. (2006). Swimming in allergens: Pool use and asthma. Environmental Health Perspectives, 114(10), A600. Retrieved from http://ehp.niehs.nih.gov/
Thomas, L., & Murray, V. (2008). Review of acute chemical incidents involving exposure to chlorine associated with swimming pools in England and Wales, June-October 2007. Journal of Public Health, 30(4), 391-397. doi: 10.1093/pubmed/fdn073
Uyan, Z. S., Carraro, S., Piacentini, G., & Baraldi, E. (2009). Swimming pool, respiratory health, and childhood asthma: Should we change our beliefs? Pediatric Pulmonology, 44(1), 31-37. doi: 10.1002/ppul.20947
Villanueva, C. M., Font-Ribera, L., Gómez, F. P., Barreiro, E., Zock, J., Nieuwenhuijsen, M. J.,...Kogevinas, M. (2008). Acute exposure to disinfection by-products in swimming pools and short term changes in respiratory biomarkers [Abstract]. Epidemiology, 19(6), S107 doi: 10.1097/01.ede.0000339853.71572.70
Voisin, C., & Bernard, A. (2008). Risks of allergic reactions to chlorination byproducts in swimming pools. Environnement Risques & Santé, 7(6), 417-423. doi: 10.1684/ers.2008.0181
Wattigney, W. A., Kaye, W. E., & Orr, M. F. (2007). Acute hazardous substance releases resulting in adverse health consequences in children: Hazardous substances emergency events surveillance system, 1996-2003. Journal of Environmental Health, 70(4), 17-24. Retrieved from http:// www.neha.org/JEH/
Weaver, W. A., Li, J., Wen, Y., Johnston, J., Blatchley, M. R., & Blatchley, E. R., III. (2009). Volatile disinfection by-product analysis from chlorinated indoor swimming pools. Water Research, 43(13),3308-3318. doi: 10.1016/ j.watres.2009.04.035
Weisel, C. P., Richardson, S. D., Nemery, B., Aggazzotti, G., Baraldi, E., Blatchley, E. R., III, ... & Sattar, S. (2009). Childhood asthma and environmental exposures at swimming pools: State of the science and research recommendations. Environmental Health Perspectives, 117(4), 500- 507. doi: 10.1289/ehp.11513
World Health Organization. (2006). Guidelines for safe recreational water environments. Volume 2: Swimming pools and similar environments. Retrieved from http://apps.who.int/iris/bitstream/10665/43336/1/9241546808_eng.pdf?ua=1
Zwiener, C., Richardson, S. D., DeMarini, D. M., Grummt, T., Glauner, T., & Frimmel, F. H. (2007). Drowning in disinfection by products? Assessing swimming pool water. Environmental Science & Technology, 41(2), 363-372. doi: 10.1021/es062367v
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