Swimming pools and spas oneeye in the land

Swimming pools and spas: one-eye in the land of the blind Jan Bakker, clinical occupational physician, AMC / VUmc Amsterdam, the Netherlands

What can you expect ? Three cases of “sick swimming pools” Chlorine- and bromine chemistry in swimming pools Crisis management Stakeholders New developments: • WHO: Guidelines for Safe Pools and Spas 2011 -2013 • ICOH 2012 Cancun: start WHO expertise committee

Case I lifeguard with workrelated handeczema and a calf dermatosis

Case I Occupational dermatologist of academic expertise center: • Contactallergy nickel, cobalt and thiuram-derivates (non-latex rubber) Clinical occupational physician of academic expertise center: • Workplace investigation Diagnosis: • • • Erysipelas by beta-haemolytic streptococci Combination of allergic and irritative handeczema The allergenes alone cannot explain the handeczema Work factors not causal, aggravating Health problems managable / returned to work

Case II Health complaints of visitors and lifeguards 2010 -2011 Health problems: • • • Skin: erythema, papulae, intens itching Mucous membranes: rhinitis, conjunctivitis, keratitis, astma Anaphylactic shock Standard water parameters within normal range No medical doctor involved Risk for reputation management forced to close the swimming pool Decision of management and technicians Expertise center acting as consultant

Crisis management and stakeholders Management • • Responsibel local politicians Provincial officials Swimming pool management Communication officer Technicians: • • • Installation technician Water laboratories Toxicologist Medical officers: • • Dermatologist Clinicical occupational physician Local occupational physician Public medical officer

Investigation model Expertise Center “field epidemiology” 1. Lifeguards • Specific questionnaire • Consultation on location • Workplace investigation • Contactallergologic investigation if necessary • Test-dives (n=9) 2. Visitors • Specific questionnaire if complaints • Consultation by telephone and teledermatology • Consultation on location if necessary

Epicutane contactallergologic investigation

Suspected causes Bacteria in the airconditioning Legionella Mites in the water Cleaning agens To less chalk Psycologic Mysterious factors

Results 1 Individual medical diagnosis and relationship with swimming pool: • • Mostly urticaria: Rhinitis/conjunctivitis/keratitis: Astma: Shock: swimming pool related aggravation, not causal coincidence Group diagnosis • • Simularities: Subpopulations: classical pattern atopici some sensible lifeguards

Case II health complaints as % of visitors

Proces diagnosis and costs Procesdiagnosis: • Lack of expertise on pool-chemistry • No occupational health • • Wrong salt for electrolysis o Too much brominated o In combination with “human products”: rise of disinfection byproducts Overloaded sand coal filters Costs: • • why here and now Nine months out of business 600. 000 US dollar

Case III februari 2012 Consultation Expertise Center by swimming pool manager: • 8 days after the first health complaints of lifeguards and visitors • 1 day after closing the pool • All water parameters in the normal range Crisis team on day 3 after closing with same stakeholders (case II) Same strategy as in case II • Comparable medical diagnoses Replacement of all the water and filters of the pool, starting day 6 Test dive on day 21 Reopening on dag 30 Costs: 120. 000 US dollars: 20 % of case II and no reputation damage

Conclusions and advices I Chlorinated swimming pools: most of the time without problems Management of this water: artisan profession, not evidenced based The same counts for occupational health: • • Goal: Reality: “evidence based medicine” homeopathical occupational and public health care Lack of expertise: • • • In swimming pools On local, provincial and country level Internationally: no expertise-center (not yet !) Health problems in swimming pools: • • Begin and end with a individual medical diagnosis There always sensible subpopulations

Conclusions and advices II Further investigation necessary: • • Chlorinated-and brominated desinfection byproducts Extra routine parameters in swimming pools Occupational physicians and “technicians” live in different worlds “There is room for improvement”: • • • “One-eye in the land of the blind” Much to win with existing technology And much money to save Occupational health should add value to business

WHO Guidelines on safe Pools and Spas 2011 -2013 2011 4 th International Conference Swimming Pool and Spa, Portugal: o WHO Guidelines for safe recreational water environments (2006) lacking: » Health benefits » Occupational safety and Health » In a rapidly changing technology 2011 WHO Bonn: Expertise meeting: » Drafting group on Guidelines on safe pools and spas » 16 countries: universities, ministeries, laboratories, gouvernement institutions (CDC Atlanta etc. ) 2012 Cancun: WHO-call for partipation: » Drafting group on the guideline » International medical expertise committee 2013 Rome: 5 th International Conference Swimming Pool and Spa, Rome » http: //www. icps-rome 2012. it/ : Guideline Draft

WHO-call for partipation WHO: : dr. Rohko Kim: rki@ecehbonn. euro. who. int +49 228 8150421 WHO Bonn Office Hermann-Ehlers-Strasse 10 53113 Bonn GERMANY NCv. B: drs. Jan Bakker: jan. g. bakker@amc. nl +31 654 693836 Netherlands Center of Occupational Diseases Coronel Institute AMC medical center University of Amsterdam, the Netherlands www. beroepsziekten. nl

“One-eye in the land of the blind” Thank you for your attention !