Influence of chlorinated water on the development of allergic diseases – An overview
More details
Hide details
Department of Gastroenterology, Metabolic and Internal Diseases and Dietetics, Poznań, Poland
Department of Allergology, Clinical Immunology and Internal Diseases, Bydgoszcz, Poland
Indoor swimming pools can be used all year round and serve for one of the most popular sport pursued for recreation. The positive effect of swimming arises in particular from the involvement of all the muscles of the body, decreasing the burden on the joints, as well as functional improvement of both the lungs and heart. Chlorine is typically used to disinfect swimming pool water and as a result the changes that take place lead to the formation of by-products, such as monochloramines (NH2Cl), dichloramines (NH2Cl2) i trichloramines (NH2Cl3), trihalogenometans (THM) or haloacetic acid (HAA). The highest concentration of these substances is just above the water surface and they may cause irritation of skin, eyes and mucosa of the respiratory tract. The toxic effect of high chlorine concentration and its side-products on the respiratory system is known, but the effect of low concentrations of these compounds is still not fully determined. Recent studies suggest that development of allergic diseases among swimmers may be increased by epithelial disorders driven by airway barrier dysfunction caused by chlorine irritation. Swimming in chlorinated water may be linked to symptoms of bronchial hyperreactivity, asthma and rhinitis especially in children, elite swimmers and employees of indoor swimming pools. Hypersensivity pneumonitis related to the use of swimming pools may manifest as a swimming pool or sauna user lung, most commonly caused by water polluting pathogens. The article summarizes recent data concerning the influence of chlorinated water on the development of allergic diseases.
Alina Kanikowska   
Department of Gastroenterology, Metabolic and Internal Diseases and Dietetics, Przybyszewskiego 49, 60-355 Poznań, Poland
1. Bougalt V, Boulet LP. Airways Disorders and the swimming pool. Immunol Allergy Clin N Am. 2013; 33: 395–408.
2. Bougault V, Turmel J, Levesque B, Boulet LP. The respiratory health of swimmers. Sports Med. 2009; 39(4): 295–312.
3. Bemanian MH, Shirkhoda S, Nakhjavani M, Mozafari H. Effect of swimming on peak expiratory flow rate of atopic children. Iran J Allergy Asthma Immunol. 2009; 8(2): 121–3.
4. Bernard A, Nickmilder M, Dumont X. Chlorinated pool attendance, airway epithelium defects and the risks of allergic diseases in adolescents: Interrelationships revealed by circulating biomarkers. Environ Res. 2015;140: 119–26.
5. Levai IK, Hull JH, Loosemore M, Greenwell J, Whyte G, Dickinson JW. Environmental influence on the prevalence and pattern of airway dysfunction in elite athletes. Respirology. 2016; 21(8): 1391–1396.
6. Chowdhury S, Alhooshani K, Karanfil T. Disinfection byproducts in swimming pool: Occurrences, implications and future needs. Water Res. 2014; 54: 68–109.
7. Mountjoy M, Fitch K, Boulet LP, Bougault V, van Mechelen W, Verhagen E. Prevalence and characteristics of asthma in the aquatic disciplines. J Allergy Clin Immunol. 2015; 136(3): 588–94.
8. Kim S-H, Park D-E, Lee H-S, Kang H-R, Cho S-H. Chronic low dose chlorine exposure aggravates allergic inflammation and airway hyperresponsiveness and activates inflammasome pathway. PloS One. 2014; 9(9): e106861.
9. Bernard A. Asthma and swimming: weighing the benefits and the risks. J Pediatr. 2010; 86(5): 351–352.
10. Villanueva CM, Cordier S, Font-Ribera L, Salas LA, Levallois P. Overview of disinfection by-products and associated health effects. Curr Environ Health Rep. 2015; 2(1): 107–15.
11. White CW, Martin JG. Chlorine gas inhalation: human clinical evidence of toxicity and experience in animal models. Proc Am Thorac Soc. 2010; 7(4): 257–63.
12. Seys SF, Feyen S, Keirsbilck S. An outbreak of swimming-pool related respiratory symptoms: An elusive source of trichloramine in a municipal indoor swimming pool. Environ Health. 2015; 218: 386–391.
13. Villaneuva CM, Cantor KP, Grimalt JO, Malats N, Silverman D, Tardon A, et al. Bladder cancer and exposure to water disinfection by-products through ingestion, bathing and swimming in pools. Am J Epidemiol. 2007; 165(2): 148–156.
14. Florentin A, Hautemaniere A, Hertemn P. Health effects of disinfection by-products in chlorinated swimming pools. International J Hyg Environ Health. 2011; 214: 461–469.
15. Lomax M. Airway dysfunction in elite swimmers: prevalence, impact, and challenges. Open Access J Sports Med. 2016;7: 55–63.
16. Font-Ribera L, Villanueva CM, Nieuwenhuijsen MJ, Zock JP, Kogevinas M, Henderson J. Swimming pool attendance, asthma, allergies, and lung function in the Avon Longitudinal Study of Parents and Children cohort. Am J Respir Crit Care Med. 2011; 183(5): 582–8.
17. Bernard A, Carbonnelle S, de Burbure C, Michel O, Nickmilder M. Chlorinated pool attendance, atopy, and the risk of asthma during childhood. Environ Health Perspect. 2006; 114: 1567–73.
18. Font-Ribera L, Kogevinas M, Zock JP, Nieuwenhuijsen MJ, Heederik D, Villanueva CM. Swimming pool attendance and risk of asthma and allergic symptoms in children. Eur Respir J. 2009; 34: 1304–10.
19. Valeriani F, Protano C, Vitali M, Romano Spica V. Swimming attendance during childhood and development of asthma: Meta-analysis. Pediatr Int. 2016; 59(5): 614–621.
20. Jacobs JH, Fuertes E, Krop EJ, Spithoven J, Tromp P, Heederik DJ. Swimming pool attendance and respiratory symptoms and allergies among Dutch children. Occup Environ Med. 2012; 69(11): 823–30.
21. Font-Ribera L, Villanueva CM, Gràcia-Lavedan E, Borràs-Santos A, Kogevinas M, Zock JP. Indoor swimming pool attendance and respiratory and dermal health in schoolchildren-HITEA Catalonia. Respir Med. 2014; 108(7): 1056–9.
22. Martin N, Lindley MR, Hargadon B, Monteiro WR, Pavord ID. Airway dysfunction and inflammation in pool- and non-pool-based elite athletes. Med Sci Sports Exerc. 2012; 44(8): 1433–9.
23. Romberg K, Tufvesson E, Bjermer L. Asthma is more prevalent in elite swimming adolescents despite better mental and physical health. Scand J Med Sci Sports. 2012; 22(3): 362–71.
24. Jacobs JH, Spaan S, van Rooy GB, Meliefste C, Zaat VA, Rooyackers JM, et al. Exposure to chloramine and respiratory symptoms in indoor swimming pool workers Eur Resp J. 2007; 29 (4): 690–698.
25. Rosenman KD, Millerick-May M, Reilly MJ, Flattery MJ, Weinberg J, Harrison J et al. Swimming facilities and work-related asthma. J Asthma. 2015; 52(1): 52–8.
26. Nordberg GF, Lundstrom NG, Forsberg B, Hagenbjork-Gustafsson A, Lagerkvist BJ, Nilsson J, et al. Lung function in volunteers before and after exposure to trichloramine in indoor pool environments and asthma in a cohort of pool workers. BMJ Open. 2012; 2(5): e000973.
27. Boskabady MH, Esmaeilizadeh M, Boskabady M. The effect of exposure to chlorine on pulmonary function tests and respiratory and allergic symptoms in Iranian lifeguards. Toxicol Ind Health. 2014; 30(3): 218–24.
28. Bougault V, Loubaki L, Joubert I, Turmel J, Couture C, Laviolette M, et al. Airway remodeling and inflammation in competitive swimmers training in indoor chlorinated swimming pools. J Allergy Clin Immunol. 2012; 129: 351–8.
29. Voisin C, Sardella A, Bernard A. Risks of new –onset allergic sensitization and airway inflammation after early age swimming in chlorinated pools. Int J Hyg Environ Health. 2014; 217: 38–45.
30. Schoefer Y, Zutavern A, Brockow I, Schäfer T, Krämer U, Schaaf B, et al. Health risks of early swimming pool attendance? Int J Hyg Environ Health. 2011; 304: 367–373.
31. Andersson M, Hedman L, Nordberg G, Forsberg B, Eriksson K, Rönmark E. Swimming pool attendance is related to asthma among atopic school children: a population- based study. Environ Health. 2015; 14: 37.
32. Bernard A, Nickmilder M, Voisin C. Outdoor swimming pools and the risks of asthma and allergies during adolescence. Eur Respir J. 2008; 32: 979–988.
33. Ferrari M, Schenk K, Mantovani W, Papadopoulou C, Posenato C, Ferrari P, et al. Attendance at chlorinated indoor pools and risk of asthma in adult recreational swimmers. J Sci Med Sport. 2011; 14(3): 184–9.
34. Carbonelle S, Francaux M, Doyle I, Dumont X, de Burbure C, Morel G, et al. Changes in serum pneumoproteins caused by short-term exposures to nitrogen trichloride in indoor chlorinated swimming pools. Biomarkers. 2002; 7: 464–78.
35. Sood A, Sreedhar R, Kulkarni P, Nawoor AR. Hypersensitivity pneumonitis-like granulomatous lung disease with nontuberculous mycobacteria from exposure to hot water aerosols. Environ Health Perspect. 2007; 115(2): 262–6.
36. Bougault V, Turmel J, Boulet LP. Effect of intense swimming training on rhinitis in high-level competitive swimmers. Clin Exp Allergy. 2010; 40(8): 1238–46.
37. Alves A, Martins C, Delgado L, Fonseca J, Moreira A. Exercise-induced rhinitis in competitive swimmers. Am J Rhinol Allergy. 2010; 24(5): e114–7.
38. Gelardi M, Ventura MT, Fiorella F, Fiorella ML, Russo C, Candreva T, et al. Allergic and nonallergic rhinitis in swimmers: clinical and cytological aspects. Br J Sports Med. 2012; 46(1): 54–8.
39. Stadelmann K, Stensrud T, Carlsen K-H. Respiratory symptomoms and bronchial responsiveness in competitive swimmers. Med Sci Sports Exerc. 2011; 43: 375–81.
40. Erkul E, Yaz A, Cıngı C, İnançli HM, San T, Bal C. Effects of indoor swimming pools on the nasal cytology of pool workers. J Laryngol Otol. 2014; 128(5): 442–6.
41. Angione S, McClenaghan H, LaPlante A. A Review of Chlorine in Indoor Swimming Pools and its Increased Risk of Adverse Health Effects. Revue interdisciplinaire des sciences de la santé- Int J Health Sci. 2011; 2(1): 44–51.
42. Weisel CP, Richardson SD, Nemery B, Aggazzotti G, Baraldi E, Blatchley ER 3rd, et al. Childhood asthma and environmental exposures at swimming pools: state of the science and research recommendations. Environ Health Perspect. 2009; 117(4): 500–7.