Ross Bogue raises appropriate questions.
Firstly, some background.
I first raised the issue of asthma on this newsgroup about 5 years ago. At that time, approximately
8 of 25 kids on the Golden West Swim Club senior team were on inhalers for asthma. Then the pool was
changed from a chlorination system to an ozonization system. All 8 asthmatic swimmers were able to
discontinue their inhalers. I reported this on this newsgroup and received a private e-mail from the
assistant coach of the Santa Barbara Swim Club, which trained out of both a chlorinated pool (on the
beach in downtown Santa Barbara) and at an ozonated pool (at UC Santa Barbara). The coach told me
that, like on most clubs, there were many swimmers in the chlorinated pool on inhalers, but none in
the ozonated pool. I also received an e-mail from a swim parent in New England, who reported the
opposite to our Golden West Swim Club experience. The New England team changed from a chlorine-free
disinfection system to a chlorine-based system. Where asthma had been previously unknown on the team
prior to chlorination, asthma became a serious problem thereafter. I also received an e-mail from
former US Olympic Silver and Gold medalist, David Berkoff. Berkoff had also been concerned about the
health hazards to competitive swimmers of swimming in chlorinated pools. He participated in a
research project which resulted in a peer-reviewed publication (quoted in our editorial). Berkoff
put great effort into trying to get USA Swimming to take the issue seriously and to support further
research. He was very disappointed when these efforts were not successful.
Also at this time, an international caliber swimmer (Pan Pac medalist) joined the Golden West Swim
Club. This swimmer had a long history of serious, intractable, steroid-dependent asthma. I told the
swimmer's parents that there was every likelihood that the swimmer's asthma would disappear, once
she began training in the GWSC ozonated pool. I was correct. Within two months, the swimmer was off
all medications.
Two years ago, my older daughter, who at the time had been a competitive swimmer for 10 years,
developed asthma while training at the University of California Irvine pool, which was an outdoor
pool with very high walls (which trap chlorinated air at the water's surface well below deck level,
particularly on cold mornings). This required treatment with inhaled glucocorticoids and
bronchodilators. She developed continual and nearly intractable coughing and wheezing (which
resulted in literally thousands of dollars in related medical expenses). She spent 6 months last
year in England, training in an indoor, chlorinated pool, where the asthma worsened further. She had
several very severe acute episodes and, in addition to bronchodilators, carried an emergency
epinephrine syringe at all times in her swim bag. This was "real" (not just exercise-induced)
asthma, with elevated serum IgE and eosinophilia. In late January, 2003, while on a three week
training trip with her British team to Australia, she developed a severe shoulder injury which kept
her out of the water for 6 months. Her asthma completely disappeared and she discontinued all
medications. Since September, she has resumed full time training in an indoor pool as a college
freshman varsity swimmer. Her asthma has recently begun to recur.
These anecdotes are familiar to anyone closely involved with competitive swimming; were they only
anecdotes, the situation would, perhaps, merit the benign neglect of USA Swimming. But these are not
isolated anecdotes, as our editorial notes and which swim coaches would not dispute.
Bogue raises several questions.
First, the paper was an invited editorial and was reviewed only by the journal editorial staff and
was not peer-reviewed.
Second, the writing style was intentionally confrontational. The paper was an editorial and not a
review. It was squarely addressing the same concerns raised by US Olympic medalist David Berkoff
15 years ago, which have continued to be ignored by the governing bodies of national and
international swimming.
Dr. Rushall and I feel that the short and long term health of literally tens of thousands of
children is being jeopardized needlessly (as there are available decontamination alternatives,
discussed in the editorial, which are not being explored with the deserved urgency).
With regard to the so-called lack of factual data, the following are the important points:
Firstly, it is precisely because of the publication of the recent (since year
2000) published studies that the editorial is particularly timely. In particular, the year 2002
study from Finland is of compelling importance. The authors documented a high level of asthma
in competitive swimmers. This confirmed may previous studies which are disputed by no one.
However, in the Finnish study, the authors followed the swimmers for several years after
enrollment into the study. Swimmers who continued to train had a progressively increasing
level of asthma. In athletes who discontinued swimming, asthma spontaneously disappeared in
the majority.
These findings, in the context of all the pre-existing information, including the near universal
experience of professional coaches, makes an overwhelmingly case to support our point of view, that
the lack of attention to this serious problem is "deplorable."
Of course additional research would be helpful. Berkoff tried to get USA Swimming to support such
research 15 years ago, without success. Tens of thousands of children have since suffered the
consequence of swimming-induced asthma in USA Swimming sponsored programs ever since then. It is
inexcusable and reprehensible that USA Swimming would not only fail to take a proactive role in
addressing and solving this problem, but instead would continue to provide false assurance (e.g. as
in the current issue of Splash) that swimming has a mitigating, rather than a causal, effect
relating to asthma.
Regarding the cost of chlorination alternatives, these costs must be balanced against the medical
expenses related to treating asthma, which are considerable, as my own family's experience
documents.
The following study further emphasizes this point:
Med Klin (Munich). 1996 Oct 15;91(10):670-6.
Cost of asthma therapy in relation to severity. An empirical study
Graf von der Schulenburg JM, Greiner W, Molitor S, Kielhorn A.
Institut fur Versicherungbetriebslehre, Universitat Hannover.
BACKGROUND: The aim of asthma therapy, i.e. the permanent elimination of the patient's symptoms, is
as a rule, achievable over the long-term only with the aid of anti-inflammatory drugs. As well as
medical, this approach also has considerable economic implications. The comparatively low compliance
among asthmatics makes treatment in this context all the more difficult. An alternative that
presents itself is the use of combination preparations, a mixture of a long-term prophylactic and a
therapeutic agent. PATIENTS AND METHODS: With the aid of standardised questionnaires, data were
acquired from 216 patients and assigned to subgroups in accordance with the degree of severity of
the asthma. The patients were treated in the offices of a total of 23 GPs and internists selected at
random from a complete list of all relevant practices in Germany. The use of resources, i.e. all
diagnostic and therapeutic measures, was recorded retrospectively for a period of 1 year. In this
way, all those resources of relevance to the health insurance carriers used during the observation
period were identified. In addition to direct costs, so-called indirect costs were also estimated,
i.e. in the present study the productivity loss to the economy due to illness-related absence from
work. RESULTS: The annual cost of treating adult asthmatics was calculated to be DM 3,339 for level
1 severity, DM 5,260 for level 2 severity and DM 12,016 for level 3 severity. As the illness
progresses in particular the direct cost of inpatient care and the indirect costs rise
disproportionately. The yearly expenditure for women sufferers is about DM 800 more than for male
sufferers. The direct cost of asthma treatment in children amounts to DM 2,950 for level 1, DM 3,225
for level 2, and DM 4,811 for level 3, severity. Here, drug-related costs in particular, rise
significantly as the disease progresses. CONCLUSION: One of the results of the present study is the
fact that for asthma sufferers in general, there is a positive correlation between average total
costs and degree of severity. It may thus be postulated that preventive medical treatment of asthma
that slows the progression of the illness, together with appropriate patient instruction, would have
a positive effect on the total expenditure per patient. If, for example, the appropriate use of
drugs in combination with patient instruction improved the compliance of asthmatics, lower treatment
costs and a better quality of life for the patient could be expected.
Quoted message said:Quoted message said:Quoted message said:
The above costs (much of which is related to the cost of prescription drugs) are undoubtedly lower
in German than in the USA (and the above study was published 7 years ago, and must be adjusted for
inflation and the introduction of newer and more expensive drugs and diagnostic tests).
With regard to the seemingly unrelated issues of dental erosions and cancer, it was the intention of
the authors to focus attention on the problem of training for hours per day in chlorinated pools,
and it seemed appropriate to note that there were additional medical issues beyond asthma to be
considered. In particular, the long term carcinogenic effect of intense exposure to chloramines
deserves much more attention than previously received.
It must further be noted that the long term consequences of treating childhood asthma include long
term effects such as osteoporosis and cataracts. e.g.
J Allergy Clin Immunol. 2003 Sep;112(3 Suppl):S1-40.
Inhaled corticosteroids: past lessons and future issues.
Allen DB, Bielory L, Derendorf H, Dluhy R, Colice GL, Szefler SJ.
Division of Endocrinology, University of Wisconsin Children's Hospital, Madison 53792-4108, USA.
Inhaled corticosteroids play a pivotal role in the treatment of asthma. Inhalation permits effective
delivery of the corticosteroid in high concentration to target sites within the lung while
minimizing systemic exposure. Consequently, the safety profile of inhaled corticosteroids is
markedly better than that of oral corticosteroid therapy. However, although it was first thought
that direct delivery might eliminate systemic adverse effects, this has not been confirmed by
clinical trials and experience. Inhaled corticosteroids are absorbed from the lungs into the
systemic circulation, in which they can acutely decrease growth velocity in children, an effect that
fortunately appears to be temporary and might have no effect on final adult height. In sufficient
dosages, they also produce bone mineral loss leading to osteoporosis and might increase the risk of
cataracts, glaucoma, skin atrophy, and vascular changes that increase the risk of ecchymoses.
Effective evaluation of the severity and significance of these complications is challenging because
highly sensitive tests do not reliably predict clinically significant events, and short-term
observations do not predict long-term consequences. Also, compliance wanes with long-term treatment,
and susceptibility to a particular adverse event can vary over time, even in the same individual,
because of developmental or hormonal changes. This journal supplement will review what has been
learned about the safety of inhaled cortico-steroids during the past decade, discussing some of the
questions that remain and considering the characteristics of an "ideal" inhaled corticosteroid: one
with high local activity in the lung and minimal or no adverse systemic effects.
Quoted message said:Quoted message said:Quoted message said:
It is important to emphasize that, by far, the highest risk group are children and teenagers in year
around competitive swimming programs. These swimmers have a vastly greater exposure to chloramines
than in the case of recreational and masters swimmers. Additionally, growing children have greater
vulnerability to the long term health consequences of intense exposure to chlorinated pool water.
It is past time for the competitive swimming community to address and solve this important issue.
Hopefully, it will not take something like a class action lawsuit to initiate the needed actions,
which, at a minimum, require disclosure of risks and informed consent from parents who expose their
children to these risks.
- Larry Weisenthal
