title: Swimming facilities and work-related asthma.
abstract: BACKGROUND
  Exposure to chlorinated water in swimming facilities may aggravate preexisting asthma or cause new onset asthma. This may be a particular problem for individuals who work and therefore spend prolonged time at swimming facilities. Chloramines formed by the interaction of chlorine-based disinfection products with the nitrogen in water from human sweat, urine and skin cells are the suspected causal agents.
  
  
  METHODS
  Cases were reviewed from the state surveillance systems in California (CA), Michigan (MI) and New Jersey (NJ) to identify individuals with confirmed work-related asthma (WRA) attributed to exposures in swimming pools, water parks or hydrotherapy spas. A standardized method was used to confirm cases.
  
  
  RESULTS
  A total of 44 confirmed cases of WRA were identified; 17 from 1994 to 2011 in CA, 15 from 1991 to 2012 in MI and 12 from 1990 to 2011 in NJ. A majority (52.2%) of the cases were new onset; 31.8% secondary to an acute exposure incident and 20.4% to repeated exposure. These represented 0.3-1.6% of all confirmed cases of WRA received during these time periods. Maintenance workers (34.9%) and lifeguards (31.8%) were the most common occupations.
  
  
  CONCLUSIONS
  Swimming pool workers were identified from three states where the pool environment was either a trigger of preexisting asthma or associated with new onset of WRA. Regulations to require air monitoring and improvements in ventilation are recommended to reduce exposure levels of chloramines, the presumed etiologic agents. Clinical assessment of patients with asthma should include consideration of the effect on respiratory symptoms from exposures in a swimming pool environment.
authors.affiliation: Division of Occupational and Environmental Medicine, Michigan State University , East Lansing, MI , USA .
authors.forename: Kenneth D
authors.initials: KD
authors.lastname: Rosenman
authors.forename: Melissa
authors.initials: M
authors.lastname: Millerick-May
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Reilly
authors.forename: Jennifer
authors.initials: J
authors.lastname: Flattery
authors.forename: Justine
authors.initials: J
authors.lastname: Weinberg
authors.forename: Robert
authors.initials: R
authors.lastname: Harrison
authors.forename: Margaret
authors.initials: M
authors.lastname: Lumia
authors.forename: Alicia C
authors.initials: AC
authors.lastname: Stephens
authors.forename: Marija
authors.initials: M
authors.lastname: Borjan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000395:Air Pollutants, Occupational / Q000633:toxicity*; D001249:Asthma / Q000139:chemically induced* / Q000453:epidemiology; D002140:California / Q000453:epidemiology; D002700:Chloramines / Q000633:toxicity*; D005260:Female; D006801:Humans; D006875:Hydrotherapy; D008297:Male; D008824:Michigan / Q000453:epidemiology; D008875:Middle Aged; D009515:New Jersey / Q000453:epidemiology; D009784:Occupational Diseases / Q000139:chemically induced* / Q000453:epidemiology; D016273:Occupational Exposure / Q000009:adverse effects*; D013551:Swimming Pools; D055815:Young Adult
chemical_list: D000395:Air Pollutants, Occupational; D002700:Chloramines
keywords: Choramines; chlorine; environmental trigger; epidemiology; occupational exposure