Indoor swimming pool attendance and respiratory and dermal health in schoolchildren Hitea Catalonia

Transcription

1 Indoor swimming pool attendance and respiratory and dermal health in schoolchildren Hitea Catalonia Laia Font-Ribera, CM Villanueva, E Gràcia-Lavedan, A Borràs-Santos, M Kogevinas, JP Zock Respiratory Medicine (2014) 108, Center for Research in Environmental Epidemiology (CREAL)

2 Swimming pools and health RISKS BENEFITS and injuries

3 DBPs in swimming pools Epidemiological evidence High DBP exposure: Inhalation volatile DBPs (THMs, chloramines) aerosols Dermal absorption skin permeable (THMs, (HAAs)) Accidental ingestion all Potential health effects*: Cancer carcinogenic DBPs (THMs, HAAs, other) 1 study suggesting increased risk of bladder cancer with pool attendance in Spain Respiratory, allergic diseases irritant DBP (trichloramine air) Pool workers, professional swimmers Higher respiratory symptoms, asthma Recreational swimmers (children) Higher asthma prevalence??? * CM. Villanueva and L. Font-Ribera. Ann Ist Super Sanità CM Villanueva et al. Am J Epidemiol 2007.

4 Epi studies on swimming and childhood asthma Study OR (95%CI) N Country Bernard et al (0.75, 3.55) 341 Belgium Carraro et al (0.16, 1.54) 241 Italy Kohlhammer et al (0.56, 1.41) 2,606 Germany Levesque et al (0.60, 1.80) 804 Canada Bernard et al (0.77, 6.50) 341 Belgium Schoefer et al ( ) 2,192 Germany Bernard et al outdoors 6.38 ( ) 847 Belgium Bernard et al ( ) 847 Belgium Cotter et al ( ) 121 Ireland Font-Ribera et al ( ) 3,223 Spain Font-Ribera et al ( ) 5,738 UK Jacobs et al ( ) 2,359 The Netherlands

5 Swimming and asthma: Font-Ribera 2011 The longitudinal study (clear temporality) ALSPAC birth cohort in Bristol, UK (n=5,738 children) Swimming ever before 4 Swimming frequency Respiratory symptoms by questionnaire Atopy (skin prick test) Lung function and BHR Years of age Main results: Swimming frequency did not increase the risk of allergic or respiratory symptoms including asthma, either overall or in atopic children at 7 or at 10 years of age Swimming was associated with an improved lung function (FEV1 and FVC) at 7 years of age Font-Ribera et al. AJRCCM 2011

6 Swimming and childhood asthma: Jacobs 2012 Individual exposure: swimming frequency x trichloramine level in the pool Cross-sectional; children 6-13 years of age in The Netherlands Jacobs et al. Occup Environ Med 2012

7 Other health effects related to irritant exposure in pools Wheezing, asthma Nystad 2003 Nystad 2008 Font-Ribera 2013 Voisin 2014 Babies / Preschoolers Schoolchildren Bernard 2006; Carraro 2006; Kohlhammer 2006; Levesque 2006; Bernard 2007; Schoefer 2008; Bernard 2008; Bernard 2009; Cotter 2009; Font-Ribera 2009; Font-Ribera 2011; Jacobs 2012 Dermatitis, eczema Font-Ribera 2013 Font-Ribera 2009; Font-Ribera 2011; Jacobs 2012 Allergic symptoms Font-Ribera 2009; Font-Ribera 2011; Jacobs 2012 Allergic sensitization Jacobs 2012; Voisin 2014 Infections Diarrea Schoefer 2008 Otitis Nystad 2003; Nystad 2008; Schoefer 2008; Robertson 1997; Font-Ribera 2013 Respiratory Nystad 2003; Nystad 2008; Schoefer 2008; Voisin 2010; Font-Ribera 2013; Voisin 2014 Increased risk, non increased

8 The HITEA project Overall aim: indoor air exposure and respiratory and allergic outcomes Cross-sectional study in schools (2008) Finland, The Netherlands, Catalonia 18 schools in 3 municipalities around Barcelona children at 6 to 12 years of age (mean age 9.0 years) Parental administered questionnaire, detailed swimming questions

9 Study variables Symptoms ever: Asthma Wheezing Eczema Dermatitis Rhinitis Allergic rhinitis Symptoms last 12 months: Wheezing Rhinitis Dermatitis Cold (n) Tonsillitis (n) Otitis (n) Years of age Swimming (frequency indoor, outdoor) 0 2 y 3 6 y Last 12m Sex, Older siblings, Maternal social class, Maternal education, Maternal asthma, Pets, TV watching, Tobbaco, Body mass index

10 Regular indoor swimming pool attendance (N=2,758) At least once per week during one month or more 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0-2 years 3-6 years Last 12m

11 Prevalence of symptoms (N=2,758) % Symptoms ever Symptoms last 12 months Age at first asthma attack: Mean 3.2y (SD=2.4)

12 Association between indoor swimming and symptoms 10 Multilevel models with school as a random effect, adjusted by parental asthma, age, maternal education, passive smoking, body mass index, siblings OR 95%CI Early swimming & symptoms ever Current swimming & symptoms last 12m 1 0,1

13 Assessment of potential reverse causation Swimming Symptoms? Symptoms Swimming 1.6% attended and 2.9% avoided swimming pools for health reasons The vast majority of school-aged children does not attend or avoid swimming for health reasons, as previously described in The Netherlands, UK or Spain*. Reverse causation is unlikely to be a main source of bias in epidemiological studies on swimming pool attendance and health effects during childhood. Jacobs ERJ 2012 *Font-Ribera ERJ 2009 Font-Ribera, AJRCCM 2011

14 DISCUSSION This new large population-based study indicates that regular indoor swimming during infancy does not increase respiratory, allergic or dermal symptoms in schoolchildren aged 6-12 years. Current scientific evidence do not support the hypothesis that swimming attendance during childhood increases the risk of asthma or other respiratory and allergic symptoms. More studies are needed to confirm the lack of association: Birth cohorts with prospectively collected data Improvement of exposure assessment: - Validation of questionnaire - Measure/estimate trichloramine levels

15 Integrated risk-benefit analysis Public health professionals agree that the benefits of swimming largely out-weight the potential risk of chemical contamination, but a proper quantitative risk-benefit analysis is lacking Infections Injuries Cancer Respiratory Dermal Allergy RISKS BENEFITS Babies Children Adults Elderly Drowning prevention Physical activity Obesity Neurodevelopment Respiratory Cancer

16 Laia Font Ribera ww.creal.cat Tribute to swimming, Alfredo Lanz (2004), Barcelona.