When The Pool Makes You Sick…

By Reach for the Wall staff.

Swimmers, coaches and spectators have remarked about the air quality at several recent swim meets in our region and ailments (e.g., rashes, coughing, etc.) that have resulted from those conditions.  So below is some background and useful resources for those interested.

Background

Poor air quality within indoor swimming venues has been a topic of conversation for many years.  For example, athletes have voiced their discomfort with the air quality at the Greensboro Aquatic Center (GAC), a facility that has hosted National Championship meets in 2013 and 2014, and SwimSwam ran several articles on the subject (see e.g., here and here).

Air quality problems at the GAC were caused by heavy usage of the pools and agitation of the water and chloramines that create off-gases.  Physical reactions ranged from mild to severe, with some swimmers experiencing a sore throat, itchy eyes and even skin rashes.  It took an investment of more than $350,000 to implement a solution, and since 2014, GAC has annually held the YMCA National meet (current contract ends 2017), and countless other regional, NCAA and USA Swimming- sanctioned events, bringing in tens of millions of dollars to the Greensboro community in hotel and commercial spending.

According to Susan Braman, manager of GAC, the air quality problem at Greensboro came to a head in 2012.  “We hosted the YMCA Nationals in April 2012. So, that was the first time we recognized that we had a problem. The problem was when we had a meet of that magnitude, had that many swimmers for that many days and that many hours each day. With the YMCA, there are easily 1,800 swimmers, several hundred coaches [and] a couple of thousand spectators, with a full day of warm-ups. It’s a five-day event”.

Science Behind Pool Air Quality

Pools use chlorine as a disinfectant for the water.  When the chlorine in the pool reacts with organic material (e.g., sweat, body oil, hair, or urine), it produces chloramines.  The more the water is churned (think warm ups), the more chloramines are produced.  Chloramines formed in the water then go off in a gas that settles just above the water surface. The problem isn’t the chlorine, but what chlorine turns into when combined with organics. The organics are contributed by bathers in the pool in the form of sweat, dander, urine and other organics. The chlorine reacts with the organics and produces nitrogen trichloride, aldehydes, halogenated hydrocarbons, chloroform, trihalomethanes and chloramines.

The Centers for Disease Control and Prevention (CDC) confirms that chloramines cause irritation in the eyes, skin and respiratory tract issues.  To reduce the risk of illness, the CDC recommends that indoor water facilities maintain good ventilation systems and that pool workers and swimmers swiftly report health issues.

USA Swimming has produced a 20 minute presentation, narrated by Mick Nelson that delves into the problem of water and air quality in our pools, covering the systems that are used to filter, as well as the chemical solutions that are used to treat the water in the pools.

Concerns in the DMV

Most of the swim meets in our area pass without a concern for air quality.   At some recent meets, however, swimmers, coaches and spectators remarked about the issues they had during and after the meet.  These ailments ranged from rashes, runny noses and itchy eyes to more serious issues such as chronic coughing and severe respiratory issues that resulted in physician and hospital visits.

After hearing chatter in the stands and complaints from our own swimmers of eye irritation, rashes and coughs, RFTW inquired via Twitter and Facebook whether these were isolated experiences or more widespread.  Unfortunately the incidents were not isolated.  As set forth below, both swimmers and parents complained about breathing difficulties, asthma-like attacks, fully body rashes, and (most commonly) eye irritation.

	Pool #1, Sample size ~40 respondents
	Pool #2, Sample size ~40 respondents

Some Possible Solutions

As detailed by Mick Nelson of USA Swimming in the video above, air quality is a byproduct of water quality.  It won’t matter how much air you move, exhaust or introduce if the water in the pool is constantly off-gassing (evaporating) chloramines.  That is:

• Moving bad air around the facility at more CFM’s (Cubic Feet per Minute) only negatively affects more people.
• Large fans in doorways blowing air from outdoors may seem to help at deck level but at water level the chloramines are still evaporating across the swimmers breathing area.
• Exhausting more air through vents or the HVAC system is always advisable but inefficient if we still have bad air at water level.
• Gimmicky air filters won’t work – that is treating the smoke not putting out the fire.  Air filters won’t take out all of the chloramines regardless of their marketing claims.

Good quality indoor pool air is not magic; it is a process depending on a variety of factors.

As athletes, parents and coaches, we can take steps to reduce the degradation of water quality during meets and subsequently improve the air quality.  USA Swimming identifies the items listed below to aid the community in taking steps to prevent occurrences of poor water and air quality within the facilities

Whose responsibility is a safe, healthy venue?

A safe, healthy venue is EVERYONE’S RESPONSIBILITY!

• The facility has to have the right equipment installed and it has to be properly maintained.  For example, all indoor pools need to have Medium Pressure UV units installed in the filter room, which need to be properly sized for each pool and the bulbs need to be at full strength and checked to make sure they are functioning.
• The meet host needs to ask the right questions pre-meet.  For example, before the meet (i.e., 10 days to 2 weeks before a large meet), the facility and meet host needs to make sure the meet pool has had no recent air quality issues and that they know their HVAC equipment has been recently inspected and properly maintained.   Also pre-meet, make sure the pool logs for water quality have been properly filled out. Water quality problems rarely happen overnight (except with 500+ swimmers using pool all the same day).   The CPO (Certified Pool Operator) should NOT shock the pool before or during the meet.  This accelerates the formation of chloramines regardless of published information to the contrary.
• The athletes need to take showers before entering the pool.  In Europe, for example, swimmers generally must shower before entering the pool, but in the U.S., this requirement often is ignored.
• Swimmers need to be advised to use the bathrooms and not pee in the pool.  This has to be reinforced by their coaches.  It only takes 10 swimmers peeing in a 6 lane 25 yard pool to adversely affect the water quality (and therefore the air quality).  The UV system can only treat the water when it travels through the filter room once every 6 hours.  Chloramines can form in the pool from swimmers not taking showers or not using bathroom in less than 30 minutes.
• The coaches need to educate (and support) their athletes on proper behavior in accordance with heath codes.
• Similarly, parents of age group swimmers need to constantly reinforce healthy athlete behavior.

Chloramine formation will be accelerated by:

1. Swimmers not properly showering before entering pool. There are over 70 chemicals in lotions and deodorants and shampoo/conditioners and makeup (etc) that combine with chlorine to form chloramines.
2. People using the pool rather than getting out and going to the restroom.
3. People doing a high level of aerobic activity and sweating in the water. (everyone sweats in the water – the same as if they were doing exercise on land)
4. Residues from ammonia based cleaning products that are used on decks or in shower rooms/lavatories.
5. Residues from fertilizers used on landscaping (nitrogen based) that get tracked into building on everyone’s shoes.
6. Poor air circulation and lack of fresh air introduction into the pool building.
7. Overuse of “shocking” the pool for maintenance purposes. Shocking the pool before or during a meet can form chloramines.  Never shock the pool unless there is a proven bacteria problem.
8. Improper use of certain brands of chemicals not suitable for conditions specific to a geographic area.
9. Pool filters not performing at peak efficiency. Many facilities have upgraded their pool-water filters to Regenerative DE filters which are 10 time more effective and efficient than sand filters.
10. Pools being overloaded with more swimmers than the facility was designed and rated to handle.

Many times preventative maintenance can stop problems before they start.  If a problem occurs it will most likely be during a high capacity event, usually on a weekend when it is almost impossible to find someone to fix the problem. Water Quality/Air Quality problems cannot be ignored.  If the air smells like chlorine, there is a problem.  You are most likely smelling chloramines rather than chlorine.  Chloramines in the air puts everyone at a serious health risk:

The last thing anyone wants is for a meet to be delayed or cancelled and the facility closed by the Department of Public Health.  That is what will happen if there is a health risk from chloramines.  There is a 3-part water test that will tell the concentration of chloramines vs free chlorine.  Every commercial pool is required to have one of these test kits and to log the test results three times a day minimum – usually more often during a swim meet.  This isn’t a guessing game – the problem can be identified and proven in less than 90 seconds.  It just can’t be solved quickly so prevention is the key.

We also understand that engineering and HVAC solutions that can be deployed to diffuse and eliminate the chloramine issue, including the following (note that RFTW is not affiliated with, does not endorse or receives no compensation of any kind from these suppliers):

• In a publication titled Outdoor Air for Healthy and Energy-Efficient Indoor Aquatic Facilities, dated August 16, 2017, HPAC Engineering referenced the following work at the Burdick Hall natatorium at Towson University in Towson, Maryland:
  • “Swimmers there long had complained of respiratory problems, especially an ailment known as “swimmer’s cough.” The swim coach knew the source was the buildup of chloramine gas above the water surface. The associate director of engineering for the university’s facilities-management department sought to improve the natatorium’s IAQ in the most energy-efficient and sustainable manner possible. The design team chose to use higher amounts of outdoor air for ventilation and dehumidification. This method, coupled with the use of flat-plate heat exchangers to recover energy from return air, was the most energy-efficient option.”

• Paddock Evacuators.  George Villareal, a former pool operator at Jenks Aquatic Center (JAC) in Jenks, Oklahoma, indicated that JAC installed a Paddock Evacuator as part of the pool itself.
  • “The pool (50m x 25y with 2 bulkheads) was built with the Evacuator just beyond the deck-level gutters on the long sides of the pool, and converging at one of the 25y sides before being ducted out. What happened was that Paddock made the gutters and the filtration system, as well as the bulkheads, so it’s always been there, since completion in April, 2011. As the first site, it didn’t have the latest features, which include variable strength or throttling for low or high demand. Therefore, it’s always on 100%. However, with the system always on, it always draws out chloramines which precipitate out of water, even overnight when there is no use of the pool, because of the water going over the edges of the gutters and the Evacuator trough just beyond the gutters. Water is always moving and kicking up the chloramines, and it’s always being captured and sent out. Even during times of very high pool usage, like warm-ups in both sides of the pool, when it’s 2 x 25y pools, and there may be 600 different swimmers in the pool, the air remains much better than anything I’ve ever experienced indoors. It DOES smell some during warm-up, and the air isn’t perfect, but given that there is a 15 minute dead period before events start, the system will catch up and stay ahead during that period and the rest of the day with no problems, and it’s like being outside. The effect is that during warm up, the air will never get as bad as other pools.  People in the pool area can sense the air getting progressively better in a matter of minutes. Lifeguards in the chairs will sense it first, then everyone else. It’s almost like someone pulls the plug on a tub and the bad air goes down the drain like water. After an overnight rest, both water (after 1 – 1 1/2 filter runs) and air are pristine.”

USA Swimming Insurance Resources

USA Swimming carries insurance to cover situations where a swimmer, coach or official seeks medical assistance as a result of events or conditions at a swim meet.  USA Swimming’s policy for membership protection is:

• To provide safety education for its membership;
• To provide excess accident medical protection for USA Swimming members who may suffer injuries while participating in insured activities; and
• To provide evidence of financial responsibility so that USA Swimming clubs can conduct insured activities.

When this coverage is in effect, USA Swimming members are covered while participating in a USA Swimming supervised, sponsored, sanctioned or approved event, including:

• Competitions and meets;
• Organized practice sessions;
• Approved social and fund raising activities;
• Travel to and from competitions, meets, events, organized practice sessions, approved social and fundraising activities at the direction of a coach or club board of directors;
• Observed Swim Meet events for USA Swimming Officials only

When covered injuries result in treatment by a legally qualified physician beginning within 90 days of the accident, the medical expense incurred in excess of the medical deductible, if any, will be paid, but benefits will not exceed a maximum of $25,000.  Benefits must be medically necessary and cannot exceed the usual and customary charges in the geographic area where treatment is performed. Only covered medical expenses incurred by the insured within 52 weeks from the date of the accident are covered.

How to File a Claim

To file a claim, send a completed Report of Occurrence form and verification of the injured party’s USA Swimming membership to the USA Swimming National Headquarters and Risk Management Services, Inc.  Once received, USA Swimming National Headquarters will send a confirmation email and claim forms are sent to the injured party, or the party’s parents if a minor.  All bills must be submitted to any group hospital/medical and/or HMO coverage for which the member is eligible. Copies of any Explanation of Benefits (paid or denied) documents from an individual or group hospital/medical and/or HMO coverage must accompany all itemized bills.

Completed claim forms should be submitted to the insurance company as directed on the claim form.  Additional claim forms may be obtained by contacting USA Swimming National Headquarters.  [This description of coverage summarizes the provisions of the insurance policy issued to USA Swimming. Should there be any discrepancy between the policy and this description, policy provisions will prevail.]

The insurance coverage may require that no person admits liability or responsibility or discusses any aspect of an incident with anyone other than an authorized insurance company claims representative of USA Swimming, law enforcement authorities or emergency medical personnel.

References:

1. Aquatics The Air in There. Greensboro Aquatic Center in Greensboro, N.C. By Deborah L. Vence Retrieved from Recreation Management Online September Edition 
2. CDC. (n.d.). Chloramines & pool operation. Retrieved from https://www.cdc.gov/healthywater/swimming/aquatics-professionals/chloramines.html
3. Lochner, G. (2017). Special operating modes. Available at https://tinyurl.com/pools-special-modes
4. Lochner, G. (2016). Ventilation and air distribution in indoor aquatic facilities. Available at https://tinyurl.com/pools-ventilation
5. Innovent. (2010, August). Natatorium dehumidification units improve IAQ, boost energy efficiency. HPAC Engineering, pp. 22-23. Available at http://bit.ly/Innovent_0810
6. SwimSwam, multiple articles, linked inline
7. Mick Nelson, Facilities Development Department- USA Swimming