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Clifford P. Weisel,¹ Susan D. Richardson,² Benoit Nemery,³ Gabriella Aggazzotti,⁴ Eugenio Baraldi,⁵ Ernest R. Blatchley III,⁶ Benjamin C. Blount,⁷ Kai-Håkon Carlsen,⁸ Peyton A. Eggleston,⁹ Fritz H. Frimmel,¹⁰ Michael Goodman,¹¹ Gilbert Gordon,¹² Sergey A. Grinshpun,¹³ Dirk Heederik,¹⁴ Manolis Kogevinas,^15,16,17,18 Judy S. LaKind,¹⁹ Mark J. Nieuwenhuijsen,²⁰ Fontaine C. Piper,²¹ and Syed A. Sattar²²

¹Environmental and Occupational Health Sciences Institute, Robert Wood Johnson Medical School/University of Medicine and Dentistry of New Jersey, Piscataway, New Jersey, USA; ²U.S. Environmental Protection Agency, National Exposure Research Laboratory, Athens, Georgia, USA; ³Catholic University of Leuven, Research Unit of Lung Toxicology, Laboratory of Pneumology, Leuven, Belgium; ⁴University of Modena and Reggio Emilia, Dipartimento di Scienze di Sanità Pubblica, Modena, Italy; ⁵Department of Pediatrics, Unit of Allergy and Respiratory Medicine, University of Padova, Padova, Italy; ⁶School of Civil Engineering, Purdue University, West Lafayette, Indiana, USA; ⁷National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; ⁸Faculty of Medicine, University of Oslo, Norwegian School of Sport Sciences, Oslo, Norway; ⁹Johns Hopkins University (retired), Baltimore, Maryland, USA; ¹⁰Engler-Bunte-Institute, Department of Water Chemistry, University of Karlsruhe, Karlsruhe, Germany; ¹¹Department of Epidemiology, Rollins School of Public Health, Emory University, Georgia, USA; ¹²Department of Chemistry and Biochemistry, Miami University, Oxford, Ohio, USA; ¹³Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; ¹⁴Division of Environmental and Occupational Health, The Netherlands Institute for Risk Assessment Sciences, University of Utrecht, Utrecht, The Netherlands; ¹⁵Centre for Research in Environmental Epidemiology, Barcelona, Spain; ¹⁶Municipal Institute of Medical Research (IMIM-Hospital del Mar), Barcelona, Spain; ¹⁷CIBER Epidemiologia y Salud Pública, Spain; ¹⁸Medical School, University of Crete, Heraklion, Greece; ¹⁹LaKind Associates, LLC, Catonsville Maryland, USA; ²⁰Environmental Epidemiology, Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain; ²¹Truman State University (retired), Education Committee National Swimming Pool Foundation, Bushkill, Pennsylvania, USA; ²²Centre for Research on Environmental Microbiology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

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.

Key words: aerosols, biologics, childhood asthma, DBPs, disinfection by-products, epidemiology, study design, swimming pools. Environ Health Perspect 117:500–507 (2009) . doi:10.1289/ehp.11513 available via http://dx.doi.org/ [Online 30 September 2008]

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@eohsi.rutgers.edu

The multidisciplinary workshop expert panel authored this article. The workshop was cochaired by C.P.W., S.D.R., and B.N. and was organized by the Research Foundation for Health and Environmental Effects with grants from the World Chlorine Council and participating organizations and the National Swimming Pool Foundation.

This paper has been reviewed in accordance with the peer and administrative review policies of the U.S. Environmental Protection Agency (EPA) and Centers for Disease Control and Prevention (CDC) and approved for publication. The views expressed in this report are those of the authors and do not necessarily reflect the opinions and/or policies of the U.S. EPA or CDC. Mention of trade names or commercial products does not constitute endorsement or recommendation for use by the EPA or CDC.

All participants received support for travel and/or lodging, and C.P.W., G.A., E.B., E.R.B., K.-H.C., P.A.E., F.H.F., M.G., G.G., S.G., D.H., F.C.P., and S.S. also received an honorarium. The Research Unit of Lung Toxicology of the Catholic University of Leuven received an honorarium, and J.S.L. received support for her role as workshop facilitator frm the Research foundation for Health and Environment, and consults to industry and government. E.R.B. has received grants for research on swimming pool chemistry from DuPont Experimental Station, the National Swimming Pool Foundation, and the American Chemistry Council. S.A.S.'s academic center receives research contracts from makers of environmental surface disinfectants and hand antiseptics ; he advises many such companies through his company Canlinks International, and is on the board of directors of Virox Tech. The other authors declare they have no competing financial interests.

Received 26 March 2008 ; accepted 30 September 2008.