Respiratory symptoms and bronchial responsiveness in lifeguards exposed to nitrogen trichloride in indoor swimming pools.
Open accessAbstract
OBJECTIVES: To measure the levels of exposure to nitrogen trichloride (NCl3) in the atmosphere of indoor swimming pools and to examine how they relate to irritant and chronic respiratory symptoms, indices of pulmonary function, and bronchial hyperresponsiveness to methacholine in lifeguards working in the pools. METHOD: 334 lifeguards (256 men; 78 women) recruited from 46 public swimming pools (n = 228) and 17 leisure centre swimming pools (n = 106) were examined. Concentrations of NCl3 were measured with area samplers. Symptoms were assessed by questionnaire and methacholine bronchial challenge (MBC) test by an abbreviated method. Subjects were labelled MBC+ if forced expiratory volume in one second (FEV1) fell by > or = 20%. The linear dose-response slope was calculated as the percentage fall in FEV1 at the last dose divided by the total dose given. RESULTS: 1262 samples were taken in the 63 pools. Mean NCl3 concentrations were greater in leisure than in public pools. A significant concentration-response relation was found between irritant eye, nasal, and throat symptoms-but not chronic respiratory symptoms-and exposure concentrations. Among women, the prevalence of MBC+ was twice as great as in men. Overall, no relation was found between bronchial hyperresponsiveness and exposure. CONCLUSIONS: The data show that lifeguards exposed to NCl3 in indoor swimming pools are at risk of developing irritant eye, nasal, and throat symptoms. Exposure to NCl3 does not seem to carry the risk of developing permanent bronchial hyperresponsiveness, but this association might have been influenced by self selection. The possibility that subjects exposed to NCl3 are at risk of developing transient bronchial hyperresponsiveness cannot be confidently ruled out.
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In Massin et al., despite the large number of chloramine measurements, no associations were studied between chloramine levels and basic characteristics such as number of bathers, disinfection methods and free chlorine concentrations in water.
“Furthermore, despite the large number of chloramine measurements, no associations were studied between chloramine levels and basic characteristics, such as the number of bathers, disinfection methods and (free) chlorine concentrations in the water.”
From Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers (2007) · cites this paper as [3]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredConditions that determine production and air levels of trichloramines are believed to depend on the degree of water chlorination, contamination of water by nitrogen-containing compounds, water temperature, water circulation and ventilation.
“Conditions that determine production and air levels of trichloramines are believed to depend on the degree of water chlorination, contamination of water by nitrogen-containing compounds (which depends on the number of bathers, as well as their behaviour and hygiene), water temperature, water circulation and ventilation 3, 4.”
From Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers (2007) · cites this paper as [3]
The Discussion (page not provided) says nitrogen trichloride forms when chlorine reacts with nitrogen-containing substances such as sweat and urine. It also suggests that temperature, air recycling, and water-surface disturbances affect airborne concentrations. It does not specifically identify the degree of chlorination, water circulation, or ventilation as determinants, so the full list is not supported by this copy. (LLM, conf=0.85)
Experimental — accuracy not yet measuredNitrogen trichloride concentrations were greater in leisure pools (mean±sd, 0.67±0.17 mg·m−3) than public pools (0.24±0.37 mg·m−3).
“Nitrogen trichloride concentrations were greater in leisure pools (mean±sd, 0.67±0.17 mg·m−3) than public pools (0.24±0.37 mg·m−3)”
From Occupational asthma caused by chloramines in indoor swimming-pool air (2002) · cites this paper as [6]
The Exposure Assessment section reports higher mean NCl₃ concentrations in leisure centre pools than in public pools, matching the claim's comparison and means. However, the standard deviations are reversed: the paper gives 0.67 ± 0.37 mg/m³ for leisure pools and 0.24 ± 0.17 mg/m³ for public pools. (LLM, conf=0.95)
Experimental — accuracy not yet measuredPersonnel in swimming pool facilities typically experience ocular and respiratory symptoms.
“Personnel in swimming pool facilities typically experience ocular and respiratory symptoms. [11,16 -19]”
From Occupational exposure to trichloramine and trihalomethanes: adverse health effects among personnel in habilitation and rehabilitation swimming pools (2019) · cites this paper as [11]
The Respiratory and Irritant Symptoms section reports frequent irritant symptoms, including eye irritation, among lifeguards at indoor pools. But it reports low prevalence of chronic respiratory symptoms. The claim extends those findings to swimming-pool personnel generally and does not distinguish respiratory irritation from chronic respiratory symptoms. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe emission of unwanted by-products from pool water into indoor air depends on factors such as concentration in water and volatility, number of bathers and behavior, ventilation, water temperature and water circulation.
“The emission of unwanted by-products from the pool water into the indoor air depends on different factors such as the concentration in the water and their volatility, the number of bathers and their behavior, ventilation, water temperature and water circulation. [2,9 -12]”
From Occupational exposure to trichloramine and trihalomethanes: adverse health effects among personnel in habilitation and rehabilitation swimming pools (2019) · cites this paper as [11]
The Discussion (page unavailable) suggests that higher water and air temperatures, recycled air, and water-surface disturbances can increase airborne nitrogen trichloride in indoor pools. It does not address water concentration or volatility, bather numbers or behavior, or water circulation; its reference to air recycling is not a general finding about ventilation. The paper also presents the identified factors as likely explanations, not established determinants of emissions. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Most stationary air measurements during pool work had exposure levels (arithmetic mean) usually 0.15-0.65 mg/m3 for public and school baths and 0.2-1.25 mg/m3 for adventure baths.
“The exposure levels (arithmetic mean; AM) were usually 0.15-0.65 mg/m 3 for public and school baths and 0.2-1.25 mg/m 3 for adventure baths”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
The Exposure Monitoring section describes stationary area sampling during lifeguards’ shifts, and Exposure Assessment reports mean nitrogen trichloride concentrations for public and leisure-centre pools. It does not report the claimed 0.15–0.65 and 0.2–1.25 mg/m³ ranges or identify school and adventure baths as the categories measured. Page numbers are unavailable in our copy. (LLM, conf=0.86)
Experimental — accuracy not yet measuredNo significant associations have been found between levels or duration of trichloramine exposure and self-reported asthma symptom, pulmonary function, airway hyperreactivity and airway inflammation.
“No significant associations have been found between levels or duration of trichloramine exposure and self-reported asthma symptom, pulmonary function, airway hyperreactivity and airway inflammation.”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
The Discussion reports no association between trichloramine exposure and chronic respiratory symptoms, and the Abstract reports no overall association with bronchial hyperresponsiveness. However, Table 4 shows a borderline association between cumulative exposure and forced vital capacity in men (p=0.05), while measured exposure was significantly associated with irritant symptoms. The paper does not report a measure of airway inflammation, so it cannot support that part of the claim. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIrritative symptoms in eyes and upper respiratory tract are evident at airborne trichloramine levels of 0.5 mg/m3.
“Irritative symptoms in eyes and upper respiratory tract are evident at airborne trichloramine levels of 0.5 mg/m 3 (H ery et al. 1995; Massin et al. 1998; Fantuzzi et al. 2013).”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
Table 3 (Bronchial Responsiveness section; page not provided) reports eye, nose, and sore-throat symptoms among lifeguards in the exposure group above 0.50 mg/m³. It also reports symptoms below that level, so the paper supports the association but does not establish 0.5 mg/m³ as a precise level at which symptoms become evident. (LLM, conf=0.84)
Experimental — accuracy not yet measuredMassin et al. found no associations between trichloramine exposure and bronchial hyperresponsiveness, chronic bronchitis and asthma in 334 French lifeguards.
“No associations were found between exposure and BHR, chronic bronchitis and asthma.”
From Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers (2007) · cites this paper as [3]
Massin et al. found that trichloramine exposure was significantly associated with upper respiratory symptoms.
“Trichloramine exposure was significantly associated with upper respiratory symptoms.”
From Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers (2007) · cites this paper as [3]
In Massin et al., no comparison was made with the general population.
“In that study, no comparison was made with the general population.”
From Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers (2007) · cites this paper as [3]
A dose/response relationship was found between nasal, eye and throat symptoms but not chronic respiratory symptoms.
“A dose/response relationship was found between nasal, eye and throat symptoms but not chronic respiratory symptoms.”
From Occupational asthma caused by chloramines in indoor swimming-pool air (2002) · cites this paper as [6]
No relationship has previously been found between chloramines and bronchial hyperresponsiveness or asthma.
“but no relationship has previously been found with bronchial hyperresponsiveness or asthma 6.”
From Occupational asthma caused by chloramines in indoor swimming-pool air (2002) · cites this paper as [6]
There was no correlation between bronchial hyperresponsiveness to methacholine and exposure to chloramines.
“There was no correlation between bronchial hyperresponsiveness to methacholine and exposure to chloramines.”
From Occupational asthma caused by chloramines in indoor swimming-pool air (2002) · cites this paper as [6]
Massin et al. studied 334 lifeguards working in 46 public swimming pools (n=228) and 17 leisure centre swimming pools.
“Massin et al. 6 studied 334 lifeguards working in 46 public swimming pools (n=228) and 17 leisure centre swimming pools.”
From Occupational asthma caused by chloramines in indoor swimming-pool air (2002) · cites this paper as [6]
The experiment was designed to produce nitrogen trichloride at a concentration of 0.5 mg·m−3 in a challenge chamber, this concentration being at the upper end of the range measured in swimming pools.
“The experiment was designed to produce nitrogen trichloride at a concentration of 0.5 mg·m−3 in a challenge chamber, this concentration being at the upper end of the range measured in swimming pools 1, 6.”
From Occupational asthma caused by chloramines in indoor swimming-pool air (2002) · cites this paper as [6]
Irritation (respiratory and ocular) associated with exposure to CAMs, particularly TCAM, among swimming pool attendees or workers is well acknowledged.
“Irritation (respiratory and ocular) associated with exposure to CAMs (particularly TCAM) among swimming pool attendees or workers are well acknowledged [8,9,10,11,12,13,14,15].”
From Occurrence and Spatial and Temporal Variations of Disinfection By-Products in the Water and Air of Two Indoor Swimming Pools (2012) · cites this paper as [11]
Duration of exposure was taken into account in some studies, and an association between the prevalence of irritation in upper airways or eyes and cumulative trichloramine exposure was observed.
“Duration of exposure was taken into account in some studies, and an association between the prevalence of irritation in upper airways or eyes and cumulative trichloramine exposure was observed (Massin et al. 1998;Jacobs et al. 2007;Parrat et al. 2012).”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
The LOAEC value of around 0.4 mg/m3 is supported by several other studies on pool workers which show irritation at approximately 0.5 mg/m3.
“This value is supported by several other studies on pool workers which show irritation at approximately 0.5 mg/m 3 (H ery et al. 1995; Massin et al. 1998; Fantuzzi et al. 2013).”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
Significantly higher prevalences of irritative symptoms in eyes and nose were reported in pool workers in one study at 0.36 (0.30-0.52) mg/m3 of trichloramine and in three other studies with pool workers from around 0.5 mg/m3.
“Significantly higher prevalences of irritative symptoms in eyes and nose were reported in pool workers in one study at 0.36 (0.30-0.52) mg/m 3 of trichloramine (Parrat et al. 2012) and in three other studies with pool workers from around 0.5 mg/m 3 (H ery et al. 1995; Massin et al. 1998; Fantuzzi et al. 2013).”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
An association between the prevalence of irritation in upper airways or eyes and cumulative trichloramine exposure was observed in some studies.
“An association between the prevalence of irritation in upper airways or eyes and cumulative trichloramine exposure was observed in some studies (Massin et al. 1998;Jacobs et al. 2007;Parrat et al. 2012).”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
Significant concentration-response trends for eye, nose and throat irritation over the whole exposure range (4 sub-groups) were reported for lifeguards.
“In addition, significant concentration-response trends for eye, nose and throat irritation over the whole exposure range (4 sub-groups) were reported for lifeguards (Massin et al. 1998).”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
Several studies reported irritation at approximately 0.5 mg/m3 of trichloramine.
“Several of these studies reported irritation at approximately 0.5 mg/m 3 of trichloramine (H ery et al. 1995;Massin et al. 1998;Fantuzzi et al. 2013).”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
Duration of exposure seems to be of importance; an association between the prevalence of irritative symptoms in exposed pool workers and cumulative trichloramine exposure has been shown.
“Duration of exposure seems to be of importance; an association between the prevalence of irritative symptoms in exposed pool workers and cumulative trichloramine exposure has been shown (Massin et al. 1998;Jacobs et al. 2007;Nordberg et al. 2012;Parrat et al. 2012).”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. 1998
In a cross-sectional study of French lifeguards, no associations between exposure levels and airway hyperresponsiveness were found.
“No associations between exposure levels and airway | hyperresponsiveness”
From Inorganic chloramines: a critical review of the toxicological and epidemiological evidence as a basis for occupational exposure limit setting (2020) · cites this paper as Massin et al. (1998)
Subjects chronically exposed to the swimming pool environment, such as pool workers, showed irritant eye, nasal, and throat symptoms.
“Subjects exposed chronically to the swimming pool environment, such as pool workers, showed irritant eye, nasal, and throat symptoms (Jacobs et al. 2007; Massin et al. 1998).”
From Short-Term Changes in Respiratory Biomarkers after Swimming in a Chlorinated Pool (2010) · cites this paper as Massin et al. 1998
For lifeguards at swimming pools, an exposure-response relationship exists between trichloramine, measured as total chloramines, and irritant eye, nasal, and throat symptoms, but not chronic respiratory symptoms or bronchial hyperresponsiveness.
“For lifeguards at swimming pools, an exposure–response relationship has been identified between trichloramine, measured as total chloramines, and irritant eye, nasal, and throat symptoms, although not chronic respiratory symptoms or bronchial hyperresponsiveness (Massin et al. 1998).”
From Childhood asthma and environmental exposures at swimming pools: state of the science and research recommendations (2009) · cites this paper as Massin et al. 1998
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- Authors
- Massin, N., Bohadana, A. B., Wild, P., Héry, M., Toamain, J. P., & Hubert, G.
- Affiliations
- Institut National de Recherche et de Sécurité (FR)
- Venue
- Occupational and Environmental Medicine
- Publisher
- BMJ
- Published
- 1998-04
- Volume
- 55
- Issue
- 4
- Pages
- 258-263
- ISSN
- 0007-1072 (ISSN-L)
- 1351-0711
- 1470-7926
- PMC
- PMC1757567
- OpenAlex
- W2168911878
- Cited by
- 181
- References
- 19
- Citations by year
- 2026: 4 · 2025: 1 · 2024: 5 · 2023: 5 · 2022: 10 · 2021: 3 · 2020: 5 · 2019: 4 · 2018: 6 · 2017: 8 · 2016: 3 · 2015: 9 · 2014: 8 · 2013: 7 · 2012: 15
- FWCI
- 2.16
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Occupational and Environmental Medicine (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Occupational exposure and asthma
- Physical Sciences › Environmental Science › Health, Toxicology and Mutagenesis › Indoor Air Quality and Microbial Exposure
- Health Sciences › Medicine › Physiology › Asthma and respiratory diseases
- Keywords
- nitrogen trichloride, indoor swimming pools, lifeguards, occupational exposure, airway hyperresponsiveness, methacholine challenge, lung function, dose-response relationship, sex differences
- MeSH terms
- Adult, Bronchial Provocation Tests, Bronchitis, Chlorides, Eye Diseases, Female, Forced Expiratory Volume, France, Humans, Irritants, Male, Nose Diseases, Pharyngitis, Regression Analysis, Respiration Disorders, Respiratory Tract Diseases, Swimming Pools, Vital Capacity, Occupational Exposure, Nitrogen Compounds
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