Pool Attendance Research Articles

Lifetime exposure to brominated trihalomethanes in drinking water and swimming pool attendance are associated with chronic lymphocytic leukemia: a Multicase-Control Study in Spain (MCC-Spain)

BackgroundChronic lymphocytic leukemia (CLL) etiology is poorly understood, and carcinogenic chemicals in drinking and recreational water are candidates.ObjectiveTo evaluate the association between drinking-water exposure to trihalomethanes (THMs) and nitrate as well as lifetime swimming pool attendance and CLL.MethodsDuring 2010–2013, hospital-based CLL cases and population-based controls were recruited in Spain, providing information on residential histories, type of water consumed and swimming pool attendance. Average THMs and nitrate levels in drinking water were linked to lifetime water consumption. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using mixed models.ResultsFinal samples for residential tap water analyses and swimming pool attendance analyses were 144 cases/1230 controls and 157 cases/1240 controls, respectively. Mean (SD) values for average lifetime residential brominated THMs and chloroform in tap water (μg/L), and ingested nitrate (mg/day) were 48.1 (35.6), 18.5 (6.7) and 13.7 (9.6) respectively in controls; and 72.9 (40.7), 17.9 (5.4), and 14.1 (8.8) in CLL cases. For each 10 μg/L increase of brominated THMs and chloroform lifetime-average levels, the ORs (95% CI) were 1.22 (1.14, 1.31) and 0.54 (0.34, 0.87), respectively. For each 5 mg/day increase of ingested nitrate, the OR of CLL was 0.91 (0.80, 1.04). The OR of lifetime pool users (vs. non-users) was 2.38 (1.61, 3.52). Upon performing annual frequency of attending pools analysis through categorization, the second and third categories showed an ORs of 2.36 (1.49, 3.72) and 2.40 (1.51, 3.83), respectively, and P-trend of 0.001.Impact statementThis study identifies an association of long-term exposure to THMs in drinking water, at concentrations below the regulatory thresholds and WHO guidelines, and swimming pool attendance, with chronic lymphocytic leukemia (CLL). These unprecedented findings are highly relevant since CLL is an incurable cancer with still unknown etiology and because the widespread exposure to chlorination by-products that remain in drinking and recreational water worldwide. Despite the demonstrated carcinogenicity in animals of several chlorination by-products, little is known about their potential risks on human health. This study makes a significant contribution to the search for environmental factors involved in the etiology of CLL and to the evidence of the health impact of these high prevalent water contaminants.

OCULAR DISCOMFORT IN PROFESSIONAL POLO-WATER PLAYERS: A PRACTICAL EXPERIENCE WITH TOPICAL HYALURONIC ACID AND GLYCURONATE ENOXOLONE.

Professional polo-water athletes are exposed to chlorine in the swimming pool. Chlorine is an irritant agent, so polo-water athletes commonly experience irritative eye symptoms. Hyaluronic acid and glycuronate enoxolone exert anti-inflammatory and cytoprotective activity. Therefore, the present practical experience explored the efficacy and safety of eye drops containing both components. The current study included 59 professional polo-water athletes. The ocular surface disease index (OSDI) and dry eye-related quality of life (QoL) score (DEQS) questionnaires were used to assess the efficacy. Subjects took the eye drops for one month. The study consisted of a baseline visit (T0) and an end-treatment one (T1). Athletes experienced a significant improvement in symptoms and QoL as assessed by OSDI and DEQS scores (p < 0.001 for both). The present study showed that professional polo-water athletes frequently experience ocular discomfort associated with swimming pool attendance. Eye drops with hyaluronic acid and glycuronate enoxolone can significantly relieve eye symptoms and improve the quality of life in these athletes.

The impact of lifestyle upon the probability of late bacterial infection after soft-tissue filler augmentation.

Purpose: Little is known about the influence of lifestyle-related factors upon the risk of late bacterial infection (LBI) emerging at the site of soft-tissue filler augmentation. The aim of this study was to analyze the impact of some such factors on the risk of LBI by comparing their respective prevalence between two groups of previously healthy women: a group in which infection occurred at a site of cross-linked hyaluronic acid (HA) augmentation and a second group which did not have such an infection.Patients and methods: The infection group featured 25 women who developed LBI at a site of cross-linked HA augmentation; the control group featured 92 women who did not experience complications during a 24-month period of observation after the same procedure. Data was analyzed statistically using Chi-square tests and logistic regression.Results: The two groups did not differ significantly in terms of age. However, the frequency of antibiotic therapy, household pet ownership, occupation, hormone replacement therapy or contraception use, and attendance at a swimming pool, sauna, or gym attendance were found to vary with statistical significance, P<0.05.Conclusions: Women in the control group practiced a more active lifestyle. Antibiotic therapy in the year preceding cross-linked HA augmentation was a factor which rendered a patient predisposed towards the development of LBI. Pet ownership was more prominent among women who did not suffer LBI than within the group in which soft tissue filler-related complications had occurred.

Swimming pool exposure is associated with autonomic changes and increased airway reactivity to a beta-2 agonist in school aged children: A cross-sectional survey.

BackgroundEndurance swimming exercises coupled to disinfection by-products exposure has been associated with increased airways dysfunction and neurogenic inflammation in elite swimmers. However, the impact of swimming pool exposure at a recreational level on autonomic activity has never been explored. Therefore, this study aimed to investigate how swimming pool attendance is influencing lung and autonomic function in school-aged children.MethodsA total of 858 children enrolled a cross sectional survey. Spirometry and airway reversibility to beta-2 agonist, skin-prick-tests and exhaled nitric oxide measurements were performed. Pupillometry was used to evaluate autonomic nervous function. Children were classified as current swimmers (CS), past swimmers (PS) and non-swimmers (NS), according to the amount of swimming practice.ResultsCurrent swimmers group had significantly lower maximum and average pupil constriction velocities when compared to both PS and NS groups (3.8 and 5.1 vs 3.9 and 5.3 vs 4.0 and 5.4 mm/s, p = 0.03 and p = 0.01, respectively). Moreover, affinity to the beta-2 agonist and levels of exhaled nitric oxide were significantly higher in CS when compared to NS (70 vs 60 mL and 12 vs 10 ppb, p<0.01 and p = 0.03, respectively). A non-significant trend for a higher risk of asthma, atopic eczema and allergic rhinitis was found with more years of swimming practice, particularly in atopic individuals (β = 1.12, 1.40 and 1.31, respectively). After case-case analysis, it was possible to observe that results were not influenced by the inclusion of individuals with asthma.ConclusionsConcluding, swimming pool attendance appears to be associated with autonomic changes and increased baseline airway smooth muscle constriction even in children without asthma.

Nasal epithelium injury by chlorination products and other stressors predicts persistent sensitization to aeroallergens in young schoolchildren

BackgroundAllergic sensitization during childhood is a dynamic process with a substantial rate of remission. Factors influencing this process are largely unknown. MethodsWe conducted a two-year prospective study among 121 schoolchildren (mean age, 5.8 years; 64 boys). We measured urea, club cell protein (CC16), β2-microglobulin and albumin in nasal lavage fluid (NALF) and IgE to cat, pollen or house dust mite (HDM) in nasal mucosa fluid. ResultsOdds of persistent sensitization to any aeroallergen increased across baseline ascending tertiles of urea-adjusted β2-microglobulin or albumin and descending tertiles of albumin- or β2-microglobulin-adjusted CC16 (P-trend = 0.006, 0.02, 0.044 and 0.006, respectively). Persistent HDM sensitization also increased with baseline descending tertiles of raw or urea-adjusted CC16 (both P-trend = 0.007). Such strong associations were not observed with new-onset or remitted sensitization to any aeroallergen or with raw NALF concentrations of urea, albumin or β2-microglobulin. At baseline, house cleaning with bleach and chlorinated pool attendance emerged among the strongest and most consistent determinants of NALF biomarkers, being both associated with higher urea and lower CC16 in NALF. ConclusionIn young children, a defective nasal epithelium attributable to immaturity or stressors such as chlorination products is predictive of more persistent aeroallergen sensitization.

Swimming attendance during childhood and development of asthma: Meta-analysis.

The association between asthma and swimming pool attendance has not been demonstrated and currently there are conflicting results. In order to clarify the association between asthma diagnosis in children and swimming pool attendance, and to assess the consistency of the available epidemiological studies, we completed a literature analysis on the relationship between the exposure to disinfection by-products in indoor swimming pools during childhood and asthma diagnosis. Following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) criteria, a systematic review and meta-analysis was performed by searching MEDLINE via PubMed, TOXNET, and Scopus databases (from inception to 20 April 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 involving a cohort of children (0-16 years), a well-defined definition of exposure, and the presence of data on effect and variance. Studies on in vivo, in vitro or professional and accidental exposure were excluded. After a screening process, seven reports (n = 5851 subjects) were included out of a total of 2928 references. The reported OR of the association between swimming pool attendance and asthma prevalence ranged from 0.58 to 2.30. The present meta-analysis failed to identify a significant difference in asthma development between children attending swimming pools and controls (OR, 1.084; 95% CI: 0.89-1.31). Swimming in childhood does not increase the likelihood of doctor-diagnosed asthma. Based on this meta-analysis review, the association of the disease with indoor pool attendance is still unclear.

Health-Related Behaviors in Swimming Pool Users: Influence of Knowledge of Regulations and Awareness of Health Risks.

Background: Swimming pool attendance exposes users to infection and chemical risks that could be largely reduced with the adoption of healthy behaviors. This study aims to investigate if the knowledge of swimming pool regulations and awareness of health risks can be associated with users’ health-related behaviors. Methods: A cross-sectional study was conducted using self-administered questionnaires to collect data from two different target groups of swimming users: 184 adults and 184 children/adolescents. The association between specific variables and patterns of behaviors and knowledge was assessed through multivariate logistic regression models. Results: Although more than 80% of both groups declared they knew the regulations, compliance with healthy behaviors was often unsatisfactory, especially in adolescents and youth. In the children/adolescents group, healthy behaviors significantly increased with the frequency of attendance per week. In both groups, compliance increased with educational level (of parents for children/adolescents), while no positive association was observed between viewing the regulations and adopting appropriate behaviors. In the adult group, a higher knowledge/awareness of health risks was related to decreased odds of at least one unhealthy behavior. Conclusions: Guaranteeing the public display of regulations in swimming facilities is not sufficient to promote and change health-related behaviors. Much more attention should be given to educational interventions aimed to increase knowledge of health risks and the awareness that bathers are directly responsible for their own well-being.

The Natural History of Human Polyomaviruses and Herpesviruses in Early Life--The Rhea Birth Cohort in Greece.

Sparse data exist on the patterns and determinants of acquisition of polyomaviruses and herpesviruses in childhood. We measured immunoglobulin G seroreactivity against 10 polyomaviruses (BKPyV, JCPyV, KIPyV, WUPyV, MCPyV, HPyV6, HPyV7, TSPyV, HPyV9, HPyV10) and 5 herpesviruses (Epstein Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus types 1 and 2, human herpesvirus 8) using multiplex serology on blood samples collected at birth (cord blood, n = 626) and at follow-up at 3 years (n = 81) and 4 years (n = 690) of age among the Rhea birth cohort recruited in Greece from pregnant women in 2007-2008. We used Poisson regression with robust variance to identify determinants of seropositivity at age 4. Seroprevalence of polyomaviruses ranged from 38.5% to 99.8% in cord blood and from 20.9% to 82.3% at age 4. Seroprevalence of EBV, CMV, herpes simplex virus types 1 and 2, and human herpesvirus 8 was 99.4%, 74.9%, 26.2%, 8.0%, and 1.6% in cord blood and 52.5%, 25.8%, 3.6%, 1.4%, and 0% at age 4, respectively. Determinants of seropositivity at age 4 were cord seropositivity (JCPyV, HPyV7, HPyV10, CMV), vaginal delivery (HPyV10), breastfeeding (CMV), younger age at day-care entry (BKPyV, KIPyV, WUPyV, TSPyV, HPyV10, HPyV9, EBV, CMV), and swimming pool attendance (BKPyV, KIPyV, WUPyV, HPyV10). Television viewing, parental stress, and hygiene practices were inversely associated with the seroprevalence of polyomaviruses and herpesviruses.

Swimming pool attendance is related to asthma among atopic school children: a population-based study.

BackgroundBy-products of water disinfectants have been suggested to cause asthma, especially in atopic children. However, studies on indoor swimming pool attendance and asthma in children have presented conflicting results. The present study examined the relationship between indoor swimming pool attendance and asthma among sensitized and non-sensitized children aged 11-12 years.MethodsAn extended ISAAC questionnaire was sent to the families of all children attending fifth or sixth grade, aged 11-12 years, in two municipalities in Northern Sweden in 2010. A total of 1866 participated (96% of those invited) in the questionnaire study and 1652 (89%) also participated in skin prick testing for 10 standard airborne allergens. Asthma was defined as physician-diagnosed asthma in combination with wheeze or use of asthma medication in the last 12 months. Current swimming pool attendance was reported as ≥1/week or <1/week. Logistic regression models were used for data analysis.ResultsThe prevalence of current asthma was 8.9% (10.0% of boys; 7.9% of girls) and 14% had attended indoor pools ≥1/week. Children currently attending swimming pools ≥1/week had an increased risk of current asthma. Stratified analyses for allergic sensitization adjusted for sex, parental smoking, parental asthma, and damp housing, showed a statistically significant association for current asthma only among sensitized subjects (OR 95% CI 1.90 1.09-3.32). No association was found between current pool attendance and wheeze, sensitization, rhinitis or eczema.ConclusionsThe present study supports the proposed link between indoor swimming pool attendance and asthma in sensitized children.

Chlorinated pool attendance, airway epithelium defects and the risks of allergic diseases in adolescents: Interrelationships revealed by circulating biomarkers

It has been suggested that allergic diseases might be epithelial disorders driven by various environmental stressors but the epidemiological evidence supporting this concept is limited. In a cross-sectional study of 835 school adolescents (365 boys; mean age, 15.5yr), we measured the serum concentrations of Club cell protein (CC16), surfactant-associated protein D (SP-D) and of total and aeroallergen-specific IgE. We used the serum CC16/SP-D concentration ratio as an index integrating changes in the permeability (SP-D) and secretory function (CC16) of the airway epithelium. In both sexes, early swimming in chlorinated pools emerged as the most consistent and strongest predictor of low CC16 and CC16/SP-D ratio in serum. Among girls, a low CC16/SP-D ratio was associated with increased odds (lowest vs. highest tertile) for pet sensitization (OR 2.97, 95% CI 1.19–8.22) and for hay fever in subjects sensitized to pollen (OR 4.12, 95% CI 1.28–14.4). Among boys, a low CC16/SP-D ratio was associated with increased odds for house-dust mite (HDM) sensitization (OR 2.01, 95% CI 1.11–3.73), for allergic rhinitis in subjects sensitized to HDM (OR 3.52, 95% CI 1.22–11.1) and for asthma in subjects sensitized to any aeroallergen (OR 3.38, 95% CI 1.17–11.0), HDM (OR 5.20, 95% CI 1.40–24.2) or pollen (OR 5.82, 95% CI 1.51–27.4). Odds for allergic sensitization or rhinitis also increased with increasing SP-D or decreasing CC16 in serum. Our findings support the hypothesis linking the development of allergic diseases to epithelial barrier defects due to host factors or environmental stressors such as early swimming in chlorinated pools.

Indoor swimming pool attendance and respiratory and dermal health in schoolchildren – HITEA Catalonia

Health benefits of swimming in pools may outweigh adverse health outcomes in children, but evidence from epidemiological studies is scarce or inconclusive for different health outcomes. We evaluated the association between indoor swimming pool attendance during childhood and respiratory and dermal conditions and symptoms in Catalan schoolchildren. Cross-sectional study in 2758 children aged 6-12 years from 18 primary schools in Barcelona province. Information on regular indoor swimming pool attendance in seven age periods, history of health conditions (asthma, wheezing, eczema, dermatitis, rhinitis, allergic rhinitis) and symptoms in the last 12 months (wheezing, dermatitis, rhinitis and number of cold, tonsillitis or otitis episodes) were collected through parental self-administered questionnaires. The associations between swimming pool attendance and health outcomes were evaluated using multivariate mixed logistic and Poisson regression models. Regular indoor swimming before 2 years of age was not related to having ever had asthma (Odds Ratio (OR)=1.14; 95%CI=0.73-1.77), wheezing (OR=1.02; 95%CI=0.82-1.28), or eczema (OR=1.09; 95%CI=0.87-1.36). Current indoor swimming was not associated with symptoms in the last 12 months (Incidence Rate Ratio for otitis was 0.94; 95%CI=0.77-1.15). Stratification by eczema or maternal education gave very similar results. This new large population-based study indicates that regular indoor swimming during infancy does not increase respiratory, allergic or dermal symptoms in Catalan schoolchildren aged 6-12 years.

Risks of new-onset allergic sensitization and airway inflammation after early age swimming in chlorinated pools

Irritant chlorination products in swimming pools can cause respiratory problems in swimmers but their possible implication in allergies development is still unclear. To assess prospectively whether early-life attendance at chlorinated pools increases the risks of IgE sensitization and of airways inflammation later during childhood. We conducted a two-year prospective study among 196 kindergarten children (mean age of 5.7 years, 54% of boys). We measured exhaled nitric oxide (eNO) and aeroallergen-specific IgE in nasal mucosa. Parents completed a questionnaire about the child's health, chlorinated pool attendance and potential confounders. Ever swimming at indoor or outdoor chlorinated pools before the age of three years was associated with higher odds for new-onset IgE sensitization to house dust mite (adjusted odds ratio [aOR] 2.93, 95% confidence interval [CI] 1.14-7.55) and for new-onset increased eNO (>15 ppb; aOR, 4.54, 95% CI 1.48-13.9). For both outcomes, aORs increased dose-dependently with time spent in chlorinated pools with values reaching, respectively, 3.60 (95% CI 1.21-10.7) and 5.92 (95% CI 1.72-20.5) when the cumulative pool attendance exceeded 60 h These risks appeared independently of each other, of parental history of allergies and of pre-existing diseases, including eczema, which at baseline was more prevalent in early swimmers (aOR, 2.91; 95% CI 1.23-6.89). Such associations were not seen with IgE sensitization to pollen or cat allergens. Attendance at chlorinated swimming pools in early life is associated with higher risks of new-onset airways inflammation and IgE sensitization to house dust mite, independently of other risk factors.

Swimming pool attendance, respiratory symptoms and infections in the first year of life

We evaluated the relationship between indoor and outdoor swimming pool attendance and respiratory symptoms and infections during the first year of life. A population-based mother-child cohort study was conducted in four Spanish areas (INMA project). Study subjects were recruited at pregnancy, followed to delivery and 14 months after birth. Information on swimming pool attendance and health manifestations during the first year of life was collected at 14 months: low respiratory tract infection (LRTI), persistent cough, wheezing, atopic eczema and otitis. Odds ratios and 95 % confidence interval (OR 95 %CI) were calculated by logistic regression adjusting for confounders. Among the 2,205 babies included, 37 % reported having LRTI, 37 % wheezing, 16 % persistent cough, 22 % atopic eczema, 33 % otitis and 50 % attended swimming pools during the first year of life. Around 40 % went to outdoor pools in summer with a median cumulative duration of 7.5 h/year, and 20 % attended indoor pools with a median cumulative duration of 18 h/year. Pool attendance differed by area, season of birth and sociodemographic characteristics, and was not associated with LRTI, wheezing, persistent cough, atopic eczema or otitis. Adjusted OR of wheezing and LRTI were, respectively, 1.06 (95 %CI, 0.88-1.28) and 1.09 (0.90-1.31) for babies attending vs. babies not attending pools. Stratification by type of swimming pool, cumulative duration or parental atopy did not modify the results. No association was detected between pool attendance and LRTI, wheezing, persistent cough, atopic eczema or otitis during the first year of life in Spain.

Health impact of disinfection by-products in swimming pools

This article is focused on the epidemiological evidence on the health impacts related to disinfection by-products (DBPs) in swimming pools, which is a chemical hazard generated as an undesired consequence to reduce the microbial pathogens. Specific DBPs are carcinogenic, fetotoxic and/or irritant to the airways according to experimental studies. Epidemiological evidence shows that swimming in pools during pregnancy is not associated with an increased risk of reproductive outcomes. An epidemiological study suggested an increased risk of bladder cancer with swimming pool attendance, although evidence is inconclusive. A higher prevalence of respiratory symptoms including asthma is found among swimming pool workers and elite swimmers, although the causality of this association is unclear. The body of evidence in children indicates that asthma is not increased by swimming pool attendance. Overall, the available knowledge suggests that the health benefits of swimming outweigh the potential health risks of chemical contamination. However, the positive effects of swimming should be enhanced by minimising potential risks.

Swimming pool attendance and respiratory symptoms and allergies among Dutch children

ObjectivesTo describe associations among swimming, respiratory health, allergen sensitisation and Clara cell protein 16 (CC16) levels in Dutch schoolchildren. Trichloramine levels in swimming pool air were determined to assess potential...

Update in Pediatric Lung Disease 2011

Asthma is the most prevalent chronic illness, and a major cause of hospitalization, in children. A large body of research is enabling physicians and researchers to better understand genetic factors, environmental factors, comorbidities, and health care factors associated with asthma symptoms and severity. Acetaminophen use has been associated with the development of asthma in numerous epidemiologic studies. Beasley and colleagues (2) surveyed 13and 14-year-olds participating in the International Study of Asthma and Allergies in Childhood (ISAAC) study to assess current symptoms of asthma, rhinoconjunctivitis, and eczema and various risk factors during the prior year. Multivariate analysis showed that recent use of acetaminophen was associated with an exposure-dependent increased risk of asthma, rhinoconjunctivitis, and eczema. Amberbir and colleagues (3) studied a birth cohort of Ethiopian children at age 1 and 3 years to assess the relationship between the use of acetaminophen and presence of geohelminth infection with the development of wheeze and eczema. Acetaminophen use was associated with a dose-dependent increase in the risk of wheeze, but not eczema. The postulated reduction in wheeze with geohelminth infection could not be evaluated because of low population prevalence. These studies are large and are consistent with other epidemiologic studies associating prenatal or direct exposure to acetaminophen with asthma symptoms. However, it is difficult to separate the effects of confounding by other factors that influence the risk of asthma, especially febrile lower respiratory tract viral infection (4). Thus, prospective, placebo-controlled studies will be needed to establish causation. The prevalence of both obesity and asthma are increasing. Cottrell and colleagues studied a cohort of 4to 12-year-olds inWest Virginia. After controlling for sex and smoking exposure, children with asthma had higher fasting triglyceride levels and a higher rate of acanthosis nigricans, a marker of abnormal glucose metabolism, regardless of body mass index (5). Although these results suggest that abnormal lipid and glucose metabolism may be associated with asthma, study limitations included classification of asthma by parental report, use of body mass index to designate obesity, and lack of adjustment for comorbidities such as sleep-disordered breathing (6). The relationship between swimming pool attendance and asthma has been inconsistent. Font-Ribera and colleagues studied a prospectively enrolled birth cohort in the United Kingdom to assess the relationship between swimming, wheezing, and allergic disease. More than half the cohort swam once or more weekly. Those who swam more frequently had a lower prevalence of asthma than those who swam less frequently; they also had an increase in forced midexpiratory flow (7). Although these data are reassuring for recreational swimmers, and suggest that pool chlorine poses a low risk overall (7, 8), there are numerous other reports that chlorination products can cause respiratory problems in elite swimmers and swimming pool workers (9). Identifying infants at high risk for allergies and asthma could be valuable in planning epidemiologic studies and in counseling families. Turner and colleagues reported the relationship between fetal size and respiratory symptoms, pulmonary function, and atopy at 10 years of age. Eachmillimeter increase in first-trimester size was associated with a 6% reduced risk of later asthma; reduced firsttrimester size was associatedwith asthma at 5 and 10 years. Low fetal growth in both the first and second trimesters was associated with an increased risk of asthma and lower lung function, and increasing fetal size between the first and second trimesters was associated with risk of eczema and hay fever (10). Chawes and colleagues evaluated biomarkers that might predict allergic disease in asymptomatic 1month-old infants. Eosinophilic protein X was associated with the development of allergic sensitization, nasal eosinophilia and eczema, but not with allergic rhinitis, blood eosinophilia, or asthma (11). Effective asthma treatment requires adherence to controller therapy. Bruzzese and colleagues (12) reported results of a schoolbased intervention, Asthma Self-Management for Adolescents (ASMA), in a randomized study comparing ASMA participants with control subjects who were placed on a wait list for the intervention. ASMAparticipants reported more confidence in managing asthma, more steps taken to prevent symptoms, better controller medication use, fewer nocturnal symptoms and activity limitations, better quality of life, and fewer acute care visits and hospitalizations. Interestingly, ASMA participants showed no improvement in managing daytime episodes, in daytime symptoms, or in school absences. Ducharme and colleagues (13) randomized children seen in the emergency room for asthma exacerbations to receive a written asthma action plan plus fluticasone and albuterol inhalers or unformatted prescriptions only. Patients who received the written action plan increased adherence to oral and inhaled steroids and to medical follow-up.

Interactions between domestic water hardness, infant swimming and atopy in the development of childhood eczema

AimRecent studies suggest that domestic water hardness and swimming in chlorinated pools may increase the prevalence of childhood eczema. The combined influence of these two factors as well as their interaction with atopic status has not been investigated. MethodsWe conducted a cross-sectional study on 358 children aged 5–6 years (54% of boys) in 30 kindergarten schools. Parents completed a questionnaire about the child's health, chlorinated pool attendance and potential confounders. Data about tap water quality were provided by water companies. Atopy was defined as a sensitization to at least one aeroallergen or as a medication for allergy. The effect of water hardness and infant swimming practice were assessed by multivariate logistic models. In addition, the effects of these risk factors combined with atopy were evaluated using two measures of biological interaction: the attributable proportion of interaction (AP) and the synergy index (S). AP>0 and S>1 indicate biological interaction between the two risk factors. ResultsWater hardness was linearly associated to the prevalence of eczema whereas the relationship of eczema with infant swimming was not linear. We observed a biological interaction between hard water (>150mg/L CaCO3L−1) and atopic status that increases the prevalence of eczema with an odds ratio (OR) of 3.30 and a 95% confidence interval (CI) of 1.34–8.15 (AP, 0.41; 95% CI 0.15–0.66 and S, 2.4; 95% CI 0.96–6.01). Infant swimming practice combined with atopy also increased the prevalence of eczema (OR, 2.72; 95% CI 1.29–5.74) although none of the interaction measures was significant. However, when water hardness and infant swimming were combined, there was no further increase of the eczema prevalence due to some form of antagonistic interaction between these two factors (AP, −0.56; 95% CI −1.12 to −0.01 and S, 0.54; 95% CI 0.33–0.87). ConclusionsOur study shows that exposure to hard water and infant swimming interact with atopic status to increase the prevalence of childhood eczema. A breaching of the epidermal barrier by detergents or salts in hard water and by chlorine-based oxidants in swimming pool water might explain these interactions.

Swimming Pool Attendance, Asthma, Allergies, and Lung Function in the Avon Longitudinal Study of Parents and Children Cohort

L Font-Ribera, CM Villanueva, MJ Nieuwenhuijsen, JP Zock, M Kogevinas, J Henderson. Am J Resp Crit Care Med. 2011;183(5):582–588 Several retrospective studies have identified attending chlorinated swimming pools during childhood as a risk factor for developing asthma and allergies later in life. These researchers collected data on a large birth cohort of children in the United Kingdom. Data were available for 5738 children from an initial cohort of 14 062 live births. Data on swimming were collected by questionnaire at ages 6, 18, 38, 42, …

SWIMMING POOL ATTENDANCE AND RESPIRATORY SYMPTOMS AT 1 YEAR: RESULTS FROM THE INMA BIRTH COHORT IN SPAIN

Background and Aims: Infant swimming pool attendance has been associated with increased respiratory diseases, but results are inconsistent. The aim was to assess the relationship between swimming pool attendance and several respiratory, atopic symptoms and infections during the first year of life. Methods: Four birth cohorts from different regions in Spain taking part of the INMA project were used. Data was collected by standard questionnaire at 12-14 months of age on frequency of swimming (indoor and outdoor swimming pools in winter and summer) and having had the following symptoms: bronchiolitis, bronchitis, low respiratory track infection (LRTI), cough, wheezing, atopic eczema, otitis. Birth season, small for gestational age, breastfeeding, day care attendance, maternal age, education, social class and atopy were considered as potential confounders. Odds ratios and 95% confidence interval (OR 95%CI) were calculated by logistic regression. Results: 2,644 children were included (855 from Valencia, 494 from Asturias, 638 from Guipuzcoa and 657 from Sabadell). Swimming pool attendance during the 1st year of age occurred among 42% of children, with a median cumulated duration of 720 minutes (Interquartile range = 210-1800). Swimming was more common among children in higher social classes with mid-aged mothers, day care attendants and those who breastfed or were born in autumn and winter. Prevalences of symptoms were 16% bronchiolitis, 14% bronchitis, 12% cough, 19% eczema, 33% LRTI, 32% wheezing and 31% otitis. Preliminary results showed no association between swimming pool attendance and symptoms. Compared to non-swimming pool attendants, children who attended swimming pools had the following adjusted OR (95%CI): bronchiolitis=1.04 (0.81-1.34), bronchitis=1.17 (0.91-1.51), wheezing=1.04 (0.86-1.25), respiratory infection=1.09 (0.91-1.32), cough=1.01 (0.78-1.31), eczema=1.03 (0.82-1.28), otitis=1.00 (0.83-1.21). Conclusions: Results showed lack of association between swimming pool attendance and respiratory symptoms during the first year of life in Spain. Further analyses considering the type of swimming pool are planned.

Socioeconomic status and exposure to disinfection by-products in drinking water in Spain

BackgroundDisinfection by-products in drinking water are chemical contaminants that have been associated with cancer and other adverse effects. Exposure occurs from consumption of tap water, inhalation and dermal absorption.MethodsWe determined the relationship between socioeconomic status and exposure to disinfection by-products in 1271 controls from a multicentric bladder cancer case-control study in Spain. Information on lifetime drinking water sources, swimming pool attendance, showering-bathing practices, and socioeconomic status (education, income) was collected through personal interviews.ResultsThe most highly educated subjects consumed less tap water (57%) and more bottled water (33%) than illiterate subjects (69% and 17% respectively, p-value = 0.003). These differences became wider in recent time periods. The time spent bathing or showering was positively correlated with attained educational level (p < 0.001). Swimming pool attendance was more frequent among highly educated subjects compared to the illiterate (odds ratio = 3.4; 95% confidence interval 1.6-7.3).ConclusionsThe most highly educated subjects were less exposed to chlorination by-products through ingestion but more exposed through dermal contact and inhalation in pools and showers/baths. Health risk perceptions and economic capacity may affect patterns of water consumption that can result in differences in exposure to water contaminants.