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      Health impact of disinfection by-products in swimming pools Translated title: Impatto sulla salute dei sottoprodotti di disinfezione nelle piscine

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          Abstract

          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.

          Translated abstract

          Questo articolo è incentrato sulle evidenze epidemiologiche riguardanti gli effetti sulla salute associati ai sottoprodotti della disinfezione (DBPs) nelle piscine, la cui presenza è una conseguenza indesiderata dei trattamenti di disinfezione per il controllo dei microrganismi patogeni. Sulla base di studi sperimentali, specifici DBPs sono risultati cancerogeni, fetotossici e/o irritanti delle vie respiratorie. Le evidenze epidemiologiche mostrano che nuotare nelle piscine durante la gravidanza non è associato ad un incremento di rischio di danni riproduttivi. Uno studio epidemiologico ha suggerito un incremento di rischio di cancro alla vescica associato alla frequentazione delle piscine, sebbene le evidenze non permettano di trarre conclusioni certe. Una più alta prevalenza di sintomi respiratori inclusa l'asma è stata trovata tra il personale che opera all'interno delle piscine e i nuotatori ad alta frequentazione, sebbene la causalità di questa associazione non sia chiara. Il peso delle evidenze nei bambini indica che l'asma non aumenta con la frequentazione delle piscine. Complessivamente, le conoscenze attuali suggeriscono che gli effetti benefici del nuotare superano i rischi potenziali per la salute dovuti alla contaminazione chimica. Tuttavia, questi effetti positivi dovrebbero essere aumentati minimizzando i rischi potenziali.

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          Most cited references179

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          Comparison of disinfection byproduct formation from chlorine and alternative disinfectants.

          Seven diverse natural waters were collected and treated in the laboratory under five oxidation scenarios (chlorine, chloramine, both with and without preozonation, and chlorine dioxide). The impact of these disinfectants on the formation of disinfection byproducts was investigated. Results showed that preozonation decreased the formation of trihalomethanes (THMs), haloacetic acids (HAAs) and total organic halogen (TOX) for most waters during postchlorination. A net increase in THMs, HAAs and TOX was observed for a water of low humic content. Either decreases or increases were observed in dihaloacetic acids and unknown TOX (UTOX) as a result of preozonation when used with chloramination. Chloramines and chlorine dioxide produced a higher percentage of UTOX than free chlorine. They also formed more iodoform and total organic iodine (TOI) than free chlorine in the presence of iodide. Free chlorine produced a much higher level of total organic chlorine (TOCl) and bromine (TOBr) than chloramines and chlorine dioxide in the presence of bromide.
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            Water disinfection by-products and bladder cancer: is there a European specificity? A pooled and meta-analysis of European case-control studies.

            Several epidemiological studies suggested an association between the risk of bladder cancer and the exposure to trihalomethanes (THMs), the main disinfection by-products (DBPs) of chlorinated water. A previous pooled analysis of case-control studies from North America and Europe estimated a summarized dose-response relation. For policy guidance of drinking water disinfection in Europe and because major differences exist in water disinfection practices and DBPs occurrence between both continents, specific risk estimates for bladder cancer in relation to DBPs exposure for European populations were needed. We conducted a pooled and a two-stage random-effect meta-analyses of three European case-control studies from France, Finland, and Spain (5467 individuals: 2381 cases and 3086 controls). Individual exposure to THMs was calculated combining information on residential history, estimates of the average total THMs (TTHM) level in tap water at the successive residences and personal water consumption. A significant odds-ratio was observed for men exposed to an average residential TTHM level > 50 μg/l (OR = 1.47 (1.05; 2.05)) when compared to men exposed to levels ≤ 5 μg/l. The linear trend of the exposure-risk association was significant (p = 0.01). Risks increased significantly for exposure levels above 25 μg/l and with more than 30 years of exposure to chlorinated water, but were mainly driven by the level rather than the duration of exposure. No significant association was found among women or with cumulative exposure through ingestion. There was no evidence of a differential exposure-response relation for TTHM and bladder cancer in Europe and North America. Consequently, a global exposure-risk relation based on 4351 cases and 7055 controls is now available.
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              Disinfection byproducts and bladder cancer: a pooled analysis.

              Exposure to disinfection byproducts in drinking water has been associated with an increased risk of bladder cancer. We pooled the primary data from 6 case-control studies of bladder cancer that used trihalomethanes as a marker of disinfection byproducts. Two studies were included from the United States and one each from Canada, France, Italy, and Finland. Inclusion criteria were availability of detailed data on trihalomethane exposure and individual water consumption. The analysis included 2806 cases and 5254 controls, all of whom had measures of known exposure for at least 70% of the exposure window of 40 years before the interview. Cumulative exposure to trihalomethanes was estimated by combining individual year-by-year average trihalomethane level and daily tap water consumption. There was an adjusted odds ratio (OR) of 1.24 in men exposed to an average of more than 1 microg/L (ppb) trihalomethanes compared with those who had lower or no exposure (95% confidence interval [CI] = 1.09-1.41). Estimated relative risks increased with increasing exposure, with an OR of 1.44 (1.20-1.73) for exposure higher than 50 microg/L (ppb). Similar results were found with other indices of trihalomethane exposure. Among women, trihalomethane exposure was not associated with bladder cancer risk (0.95; 0.76-1.20). These findings strengthen the hypothesis that the risk of bladder cancer is increased with long-term exposure to disinfection byproducts at levels currently observed in many industrialized countries.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Journal
                aiss
                Annali dell'Istituto Superiore di Sanità
                Ann. Ist. Super. Sanità
                Istituto Superiore di Sanità (Roma )
                0021-2571
                December 2012
                : 48
                : 4
                : 387-396
                Affiliations
                [1 ] Centre for Research in Environmental Epidemiology (CREAL) Spain
                Article
                S0021-25712012000400006
                10.4415/ANN_12_04_06
                23247135
                1ac4b7e6-03f5-49fb-9a2f-a3ecf7658aae

                http://creativecommons.org/licenses/by/4.0/

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                SciELO Public Health

                Self URI (journal page): http://www.scielosp.org/scielo.php?script=sci_serial&pid=0021-2571&lng=en
                Categories
                Health Care Sciences & Services

                Health & Social care
                swimming pools,disinfection by-products,epidemiology,piscine,sottoprodotti di disinfezione,epidemiologia

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