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      Childhood Asthma and Environmental Exposures at Swimming Pools: State of the Science and Research Recommendations

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          Abstract

          Objectives

          Recent studies have explored the potential for swimming pool disinfection by-products (DBPs), which are respiratory irritants, to cause asthma in young children. Here we describe the state of the science on methods for understanding children’s exposure to DBPs and biologics at swimming pools and associations with new-onset childhood asthma and recommend a research agenda to improve our understanding of this issue.

          Data sources

          A workshop was held in Leuven, Belgium, 21–23 August 2007, to evaluate the literature and to develop a research agenda to better understand children’s exposures in the swimming pool environment and their potential associations with new-onset asthma. Participants, including clinicians, epidemiologists, exposure scientists, pool operations experts, and chemists, reviewed the literature, prepared background summaries, and held extensive discussions on the relevant published studies, knowledge of asthma characterization and exposures at swimming pools, and epidemiologic study designs.

          Synthesis

          Childhood swimming and new-onset childhood asthma have clear implications for public health. If attendance at indoor pools increases risk of childhood asthma, then concerns are warranted and action is necessary. If there is no such relationship, these concerns could unnecessarily deter children from indoor swimming and/or compromise water disinfection.

          Conclusions

          Current evidence of an association between childhood swimming and new-onset asthma is suggestive but not conclusive. Important data gaps need to be filled, particularly in exposure assessment and characterization of asthma in the very young. Participants recommended that additional evaluations using a multidisciplinary approach are needed to determine whether a clear association exists.

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          Most cited references100

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          Modern epidemiology

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            Modern Epidemiology

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              Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee.

              Systematic international comparisons of the prevalences of asthma and other allergic disorders in children are needed for better understanding of their global epidemiology, to generate new hypotheses, and to assess existing hypotheses of possible causes. We investigated worldwide prevalence of asthma, allergic rhinoconjunctivitis, and atopic eczema. We studied 463,801 children aged 13-14 years in 155 collaborating centres in 56 countries. Children self-reported, through one-page questionnaires, symptoms of these three atopic disorders. In 99 centres in 42 countries, a video asthma questionnaire was also used for 304,796 children. We found differences of between 20-fold and 60-fold between centres in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema, with four-fold to 12-fold variations between the 10th and 90th percentiles for the different disorders. For asthma symptoms, the highest 12-month prevalences were from centres in the UK, Australia, New Zealand, and Republic of Ireland, followed by most centres in North, Central, and South America; the lowest prevalences were from centres in several Eastern European countries, Indonesia, Greece, China, Taiwan, Uzbekistan, India, and Ethiopia. For allergic rhinoconjunctivitis, the centres with the highest prevalences were scattered across the world. The centres with the lowest prevalences were similar to those for asthma symptoms. For atopic eczema, the highest prevalences came from scattered centres, including some from Scandinavia and Africa that were not among centres with the highest asthma prevalences; the lowest prevalence rates of atopic eczema were similar in centres, as for asthma symptoms. The variation in the prevalences of asthma, allergic rhinoconjunctivitis, and atopic-eczema symptoms is striking between different centres throughout the world. These findings will form the basis of further studies to investigate factors that potentially lead to these international patterns.
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                Author and article information

                Journal
                Environ Health Perspect
                Environmental Health Perspectives
                National Institute of Environmental Health Sciences
                0091-6765
                1552-9924
                April 2009
                30 September 2008
                : 117
                : 4
                : 500-507
                Affiliations
                [1 ] Environmental and Occupational Health Sciences Institute, Robert Wood Johnson Medical School/University of Medicine and Dentistry of New Jersey, Piscataway, New Jersey, USA;
                [2 ] U.S. Environmental Protection Agency, National Exposure Research Laboratory, Athens, Georgia, USA;
                [3 ] Catholic University of Leuven, Research Unit of Lung Toxicology, Laboratory of Pneumology, Leuven, Belgium;
                [4 ] University of Modena and Reggio Emilia, Dipartimento di Scienze di Sanità Pubblica, Modena, Italy;
                [5 ] Department of Pediatrics, Unit of Allergy and Respiratory Medicine, University of Padova, Padova, Italy;
                [6 ] School of Civil Engineering, Purdue University, West Lafayette, Indiana, USA;
                [7 ] National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA;
                [8 ] Faculty of Medicine, University of Oslo, Norwegian School of Sport Sciences, Oslo, Norway;
                [9 ] Johns Hopkins University (retired), Baltimore, Maryland, USA;
                [10 ] Engler-Bunte-Institute, Department of Water Chemistry, University of Karlsruhe, Karlsruhe, Germany;
                [11 ] Department of Epidemiology, Rollins School of Public Health, Emory University, Georgia, USA;
                [12 ] Department of Chemistry and Biochemistry, Miami University, Oxford, Ohio, USA;
                [13 ] Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA;
                [14 ] Division of Environmental and Occupational Health, The Netherlands Institute for Risk Assessment Sciences, University of Utrecht, Utrecht, The Netherlands;
                [15 ] Centre for Research in Environmental Epidemiology, Barcelona, Spain;
                [16 ] Municipal Institute of Medical Research (IMIM-Hospital del Mar), Barcelona, Spain;
                [17 ] CIBER Epidemiologia y Salud Pública, Spain;
                [18 ] Medical School, University of Crete, Heraklion, Greece;
                [19 ] LaKind Associates, LLC, Catonsville Maryland, USA;
                [20 ] Environmental Epidemiology, Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain;
                [21 ] Truman State University (retired), Education Committee National Swimming Pool Foundation, Bushkill, Pennsylvania, USA;
                [22 ] Centre for Research on Environmental Microbiology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
                Author notes
                Address correspondence to C.P. Weisel, Robert Wood Johnson Medical School, Environmental and Occupational Health Sciences Institute, Room 314, 170 Frelinghuysen Rd., Piscataway, NJ 08854 USA. Telephone: (732) 445-0154. Fax: (732) 445-0116. E-mail: weisel@ 123456eohsi.rutgers.edu
                Article
                ehp-117-500
                10.1289/ehp.11513
                2679591
                19440486
                2f967ee1-f8a2-4f33-a3b2-f8f462b920ad
                This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original DOI.
                History
                : 26 March 2008
                : 30 September 2008
                Categories
                Review

                Public health
                aerosols,biologics,childhood asthma,swimming pools,dbps,epidemiology,study design,disinfection by-products

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