Lifeguard Lung & BC Public Pools

Transcription

1 Lifeguard Lung & BC Public Pools Synthesizing Research, Policy and Risk Assessment Methods to Protect and Prevent Granulomatous Pneumonitis December 2012 Prepared by: Angela Cullen Binod Sharma Kelly Anne Cox Milad Parpouchi Suzanne Vander Wekken For: Health Science 855: Disease Prevention and Control Dr. Svetlana Kishchenko & Vanessa Wolff and Tom McKenna of the Canadian Union of Public Employees

2 This paper was an academic product produced to fulfill the requirements of Health Science 855: Disease Prevention and Control, a course of the Masters of Public Health Program at Simon Fraser University. Topic focus and consultation was provided by Vanessa Wolff and Tom McKenna from the Canadian Union of Public Employees. It is our desire that this report also provides their organization with a valuable resource document to further understand the lung condition granulomatous pneumonitis, to further case development, and to better protect the health of lifeguards and other staff working in public pool settings within the province of BC and beyond. Please contact one of the following group members with any questions or queries about this report: Angela Cullen, alcullen@sfu.ca Binod Sharma, binods@sfu.ca Kelly Anne Cox, kacox@sfu.ca Milad Parpouchi, spa16@sfu.ca Suzanne Vander Wekken, svanderw@sfu.ca

3 Table of Contents Executive Summary Introduction Background Defining Lifeguard Lung - Granulomatous Pneumonitis Hot Tub Lung Occupational Population at Risk Signs and Symptoms Causes of Lifeguard Lung Biological Causal Agents Chemical Causal Agents Exposure- Frequency and Time Dose Response Relevant Regulatory Frameworks & Policy in BC WCB and CUPE Relevant Legislation BC Pool Facility Health and Safety Legislation Other Regulatory Frameworks United States Methods for a Risk Assessment Non- carcinogenic Risk Assessment Approach and Methodology Strengths and Limitations Uncertainties in Hazard Assessment Assumptions Uncertainties in Toxicological Information Uncertainties in Exposure Parameters Applicability of ASHRAE Source Capture and Exhaust Strategy Recommendations for Improvement Prevention Monitoring at the Source Prevention & Monitoring along the Path Prevention & Monitoring at the Worker level Prevention & Monitoring at the Business/Administrative level 24 7.o Conclusion 25 References 26 Appendices i APPENDIX A: Logic Model Template ii APPENDIX B: Glossary of Terms iii APPENDIX C: Abbreviations iv APPENDIX D: Pictures and Illustrations v

4 Executive Summary Lifeguard lung, or granulomatous pneumonitis, is a medical condition that negatively affects the respiratory function of lifeguards and other aquatic staff. Aerosolized toxicants suspected to be causally associated with lifeguard lung include endotoxin, nontuberculous mycobacteria (particularly mycobacterium avium complex), and chloramines. More than 5000 persons are estimated to work at indoor pools across British Columbia (BC); it is important to reduce these workers exposures to lifeguard lung- causing toxicants. Steps to prevent new cases of lifeguard lung include: 1) worker education on the symptoms of lifeguard lung; 2) source capture and exhaust ventilation; 3) increased pool turnover; 4) balanced shift hours among pool employees; 5) reminders for patrons to take breaks during free swim and swimming lessons to use the washroom; 6) ongoing lifeguard lung risk assessments and evaluations; and 7) legislation and binding policy reflecting these recommendations. While evidence of the causal factors behind lifeguard lung continues to build, action must be taken now to protect aquatic staff from this serious respiratory condition. 1 P age

5 1.0 Introduction Swimming pools are common in many communities across Canada. These facilities provide space for residents to exercise, socialize, and learn to swim- - the last of which is an important drowning prevention strategy (Moreno, Furtner, & Rivara, 2009). While many recreational users of pools enjoy the aerobic exercise and resulting health benefits, pool workers, swim coaches, and competitive swimmers are at risk of disease from their prolonged exposure to toxicants in the indoor pool environment. CUPE currently does not have sufficient research to show how all the occupational exposures are compounding to cause lifeguard lung. This report will describe lifeguard lung, its causes, its related regulatory frameworks (both in BC and abroad), any evidence of a dose- response relationship, and the methods used to conduct the risk assessment. In addition, strengths and limitations of the risk assessment will be outlined. Finally, prevention strategies and recommendations are offered to reduce the prevalence of lifeguard lung among aquatic staff and long- term users of indoor pools. 2.0 Background 2.1 Defining Lifeguard Lung - Granulomatous Pneumonitis Lifeguard lung is a popular term for a medical condition called endemic granulomatous pneumonitis or granulomatous pneumonitis. This condition results in scarred lung tissue and impaired lung function. Lifeguard lung has been linked to chronic respiratory exposure to organic and chemical substances found in water sprays, waterfalls, and water slides, which are common features of public swimming environments such as municipal pools (Segen, 2010). The disease was first discovered and named in 1998 by Dr. Cecile Rose, an occupational medicine physician 2 Page

6 (Rose et al., 1998). 2.2 Hot Tub Lung The condition hot tub lung seems to be closely related to lifeguard lung; both present as granulomatous/hypersensitivity pneumonitis (Falkinham, 2003). Some researchers (Sood, Sreedhar, Kulkarni, & Nawoor, 2007) suggest that most cases of this physiological condition arise from exposure to hot tubs, but that indoor pools can also cause the same symptoms. As a result, scholarly work tends to differentiate the conditions by the persons afflicted (hot tub users versus pool users/staff). While there have been some speculations of alternate causes for lifeguard lung, the common indications and symptoms of both conditions give enough incentive to invoke the precautionary principle approach to risk assessment and disease prevention. This report will focus on recommendations that could work to prevent granulomatous/hypersensitivity pneumonitis in the CUPE occupational environment. Hot tub lung literature will be considered along with lifeguard lung literature to build causal evidence for granulomatous pneumonitis in CUPE aquatic workers. The term lifeguard lung will be used to encapsulate both lifeguard lung and hot tub lung, unless explicitly stated otherwise. 2.3 Occupational Population at Risk Young workers are especially vulnerable in the workplace for several reasons. For example, young workers have more life time in which toxicants to which they have been exposed can cause adverse health effects, which means that health effects can have a longer duration and/or can take away more years of potential life in young workers compared to older workers. Further, young workers are more likely to be working in a physically demanding and/or more hazardous job than older workers (WorkSafe BC, 2011). 3 P age

7 According to the Lifesaving Society, there are approximately 130 year- round indoor pools in BC with an average of 40 lifeguards and aquatic staff working at each one. This translates to between 5,200 and 6,200 lifeguards currently working in environments where they may possibly be at risk for contracting lifeguard lung (personal communication with Dale Miller, Executive Director of the Lifesaving Society of BC and the Yukon, November 15, 2012). With a total of 7,790 certified lifeguards in BC and the Yukon, there is yet another group currently not working in the field, who may have recently, or may soon be entering back into this work. With thousands of British Columbians working for public recreation facilities at risk, this health condition should be taken seriously and deserves thorough investigation, attention, and prevention efforts. 2.4 Signs and Symptoms A review of the literature shows that the signs and symptoms reported for granulomatous pneumonitis are wide- ranging, and at first sight may be comparable to influenza- like- illness (Sood, Sreedhar, Kulkarni, Nawoor, 2007). Specific signs and symptoms associated with the condition include fever, fatigue, night sweats, coughing, trouble breathing, chest discomfort, wheezing, lack of appetite, weight loss, headaches, coryza (inflammation of the mucous membranes lining the nasal cavity), nasal congestion, and bilateral crackles during inhalation (Cappelluti, Fraire, Schaefer, 2003; Hanak, Sanjay, Aksamit, Thomas, Henry, Ryu, 2006; Verma et al., 2007; Sood, Sreedhar, Kulkarni, Nawoor, 2007). Chest radiographs completed by Rose and colleagues (1998) discovered cases of lifeguard lung with diffuse interstitial opacities and permanent scarring of the lung tissue. Other health complications and conditions such as sarcoidosis (inflammatory nodules form in the lymph nodes and throughout the body), bronchitis, asthma, mycobacterial infection, 4 P age

8 bronchiolitis obliterans, eosinophilic bronchiolitis, farmer s lung, and mycotoxicosis also share similarities to lifeguard lung (Hanak et al., 2006). Workers compensation claims from lifeguards and other CUPE aquatic staff include many of these symptoms: frequent coughing, recurrent wheezing, chest tightness, congestion, mucous production and/or fever, as well as extreme difficulty breathing at the end of their shift. In addition, long term chemical sensitivities, easy irritation to smoke and chemical smells, and asthma have all been reported (personal communication, Tom McKenna, September 2012). 2.5 Causes of Lifeguard Lung Lifeguard lung is a result of working in indoor pool environments with poor air quality. Workers repeatedly inhale contaminants originating from the moist warm environments created by hot tubs, saunas, showers, swimming pools and other water features like fountains. Most indoor public pools have water sprays that circulate aerosolized water contaminants, which facilitate inhalation by patrons as well as those working in the facilities. Pool water contaminants include biological agents (endotoxin, bacteria, viruses, fungi, molds, parasites, and protozoa) as well as chemical agents commonly used to disinfect the water (e.g. chloramines, chlorine gas). A review of the literature provided some indication as to which agents are understood to be the most likely culprits of the condition Biological Causal Agents Endotoxins Two outbreaks of granulomatous pneumonitis among lifeguards working in an indoor swimming pool occurred in 1989 and 1990, respectively, and were documented by Rose et al. (1998). The indoor swimming pool associated with these two outbreaks was the first to be 5 P age

9 documented and considered to be the source of hypersensitivity pneumonitis and granulomatous pneumonitis (Rose et al., 1998). It was concluded that endotoxin exposure was the likely cause, as the level of endotoxin in the facility was 25 times higher than that of the levels immediately outside the facility (Rose et al., 1998). Endotoxins are lipopolysaccharides in the wall of gram- negative bacteria that have the potential to cause toxicity (Wang & Quinn, 2010). Nontuberculous Mycobacteria Since the Rose et al. (1998) investigation, many more case reports of similar conditions and symptoms have arisen and have been described with the term hot tub lung as the majority of cases have been related to hot tubs (i.e. Cappelluti et al., 2003; Hanak et al., 2006; Hartman, Jensen, Tazelaar, Hanak, & Ryu, 2007; Lumb et al., 2004; Rickman, Ryu, Fidler, & Kalra, 2002; Sood, Sreedhar, Kulkarni, & Nawoor, 2007; Waninger & Young, 2006). These more recent cases of hypersensitivity pneumonitis (HP) - like granulomatous lung disease, have been associated with nontuberculous mycobacteria (NTM) (Sood, Sreedhar, Kulkarni, & Nawoor, 2007, p. 262). Using various laboratory techniques, some case report investigations have been able to match the DNA of NTM found in cases to those found in specific hot tubs used by these cases (Kahana, Kay, Yakrus, & Waserman, 1997; Lumb et al., 2004). Mycobacterium Avium Complex Mycobacterium Avium Complex (MAC) is a type of NTM that has been most associated with hot tub lung, as assessed by considering the frequency of reports (Sood et al., 2007). MAC is a microorganism and major cause of death among immunocompromised individuals with AIDS (Hardy et al., 1992, as cited in Covert, Rodgers, Reyes, & Stelma, 1999). Aerosolized MAC inhalation into the lungs from hot water sources (such as hot tubs and swimming pools) has also been associated with granulomatous pneumonitis in immunocompetent individuals (i.e. 6 Page

10 Cappelluti et al., 2003; Hanak et al., 2006; Hartman, Jensen, Tazelaar, Hanak, & Ryu, 2007; Kahana et al., 1997; Lumb et al., 2004; Sood, Sreedhar, Kulkarni, & Nawoor, 2007; Waninger & Young, 2006). Sood et al. (2007) argued that cases of lifeguard lung described over ten years ago, such as Rose et al. (1998), could actually have been caused by the same NTM exposure as recent case reports, but went undetected. Four factors contribute to the persistence of viable MAC in hot tubs and indoor swimming pools: 1. Most MAC strains are highly resistant to [the] chlorine that is used to disinfect the water (Taylor, Falkinham, Norton, & LeChevallier, 2000, p. 1704). 2. MAC has been found to continue to grow at its maximal rate for five days at 42 degrees Celsius before declining (Archuleta, Mullens, & Primm, 2002), allowing it to grow in hot tubs (Sood et al., 2007). 3. Aerosolization can result in >1,000- fold increase in numbers of viable mycobacterial cells per milliliter of water droplets ejected from water (Parker, Ford, Gruft, & Falkinham, 1983, as cited in Falkinham, 2003, p. 765). 4. Poor ventilation has been pointed to as another possible contributor to persistent, aerosolized NTM and MAC in indoor swimming pools and hot tubs (Beckett, Kallay, Sood, Zuo, & Milton, 2005). This idea is further strengthened by the relatively small amount of cases of hot tub/lifeguard lung associated with outdoor pools (Sood et al., 2007). 7 P age

11 2.5.2 Chemical Causal Agents Chloramines When entering the water, people can introduce various pathogen- containing biological materials into swimming pools, including urine and sweat (Florentin, Hautemanière, & Hartemann, 2011). Swimming pool water is typically treated with disinfectants to eliminate those pathogens and microorganisms that can cause adverse health outcomes for swimmers (Florentin et al., 2011). The most commonly used disinfectant in swimming pools is chlorine gas or bleach (Florentin et al., 2011). When combined in water, these products react with the nitrogen- containing compounds in sweat and urine to produce disinfectant by- products (DBPs), like carbon dioxide and chloramines (Florentin et al., 2011; Dang et al., 2010). As a group of DBPs, chloramines include monochloramine, dichloramine and trichloramine (Florentin et al., 2011; Dang et al., 2010). Interestingly, many studies have found an association between chloramines (specifically trichloramine) and respiratory symptoms among pool staff (CDC, 2009; Dang et al., 2010; Jacobs et al., 2007; Massin et al., 1998). An explanation of the association between trichloramine and respiratory symptoms is next. Trichloramine Trichloramine (NCl3) is the most volatile of the chloramines; this means that the probability of NCL3 to vaporize (or aerosolize) is greatest among all chloramines (Jacobs et al., 2007). Further, trichloramines are understood to have a high vapour density, and consequently tend to initially accumulate in low- lying places above the pool water line (Baxter, 2012). Once aerosolized, however, trichloramines within swimming pool environments are understood to be the main chloramine associated with eye and respiratory irritation among pool staff and swimmers (Dang 8 P age

12 et al., 2010). With this, the quantity of trichloramine in the indoor swimming pool environment depends on several factors: 1. Adequacy of ventilation (Dang et al., 2010; Emanuel, 1998; Bernard, 2007) 2. Air temperature (Bernard, 2007) 3. Water Chemistry (Dang et al., 2010; Jacobs et al., 2007; Bernard, 2007) 4. Number of people in the pool introducing nitrogen compounds (Jacobs et al., 2007; Bernard, 2007) 5. Spraying equipment such as fountains and jets (Bernard, 2007; Rose, 1998) In an investigation of an outbreak of eye and respiratory irritation, including chest tightness, wheezing, cough, shortness of breath, sore throat and flu- like symptoms (CDC, 2009; Dang et al., 2010) at an indoor swimming pool, it was found that some samples taken from the facility were at [trichloramine] levels reported to cause mucous membrane irritation (Dang et al., 2010, p. 211). Moreover, lifeguards at this indoor swimming pool reported significantly more work- related symptoms than unexposed hotel employees, with the intensity of symptoms increasing on days the pool was busier (CDC, 2009, p. 81). It is important to note that elevated levels of endotoxin were also found that were similar to levels reported by Rose et al. (1998), but no cases were reported to have hypersensitivity pneumonitis (Dang et al., 2010). The authors concluded that endotoxin cannot be ruled out as a potential cause as cases may have had undetected hypersensitivity pneumonitis (Dang et al., 2010). 2.6 Exposure- Frequency and Time Dose Response Massin et al. (1998) demonstrated a concentration- response relationship between levels of trichloramine, measured in the environment of 63 indoor swimming pools, and the prevalence of 9 P age

13 eye and respiratory symptoms in 334 lifeguards. For trichloramine levels of <0.14 mg/m3 vs. >0.5mg/m3, the prevalence of eye, nose, sore throat, and dry cough symptoms was 50% vs. 85.7%, 11.6% vs. 60.5%, 16.3% vs. 28.6% and 9.3% vs. 41.8%, respectively (Massin et al., 1998). In the Netherlands, Jacobs et al. (2007) measured trichloramine levels in six indoor swimming pools and measured the prevalence of respiratory symptoms in pool staff at these facilities. The swimming pools were found to have an average trichloramine level of 0.56mg/m 3. The authors then compared the prevalence of respiratory symptoms of pool staff to that of the general Dutch population (Jacobs et al., 2007). It was found that general respiratory symptoms were significantly elevated compared with a Dutch population sample and that pool workers with greater trichloramine exposure reported upper respiratory symptoms with greater frequency (Jacobs et al., 2007, p. 690). There is a paucity of research on the time- dose response of exposure to aerosolized agents and onset and severity of lifeguard lung; however there seems to be general agreement that the longer and more frequent the exposure, the greater the risk of developing lifeguard lung. This means that frequent swimmers, swimming coaches, lifeguards, and frequent hot tub users in indoor aquatic facilities are at risk of developing lifeguard lung. Substantiated by more recent findings, a seminal outbreak investigation conducted by Rose et al. (1998) found that the risk of lifeguard lung was greater among those whose work primarily resides within the pool deck area (as opposed to the front desk or elsewhere within an aquatic centre). Further, data gathered in this investigation revealed that individuals with cases of lifeguard lung reported higher cumulative work hours than non- cases, and tended to work more hours per week. This evidence underlines a dose- response relationship in hours exposed to aerosolized pathogens and disease outcome. 10 P age

14 In considering the dose- response relationship of lifeguard lung, it should also be noted that nearly half of all persons working in aquatic centres are under 22 years old. These workers are especially vulnerable in the workplace because exposure can cause health effects with longer duration and/or can take away more years of quality life in young workers compared to older workers (WorkSafe BC, n.d.). 3.0 Relevant Regulatory Frameworks & Policy in BC Currently, there is a wide variety of legislation that speaks to health and safety for indoor pool facilities across the globe. In this report, we review legislation specific to the BC context and relevant American legislation that provides an example of well developed policies related to regulating air quality. 3.1 WCB and CUPE Relevant Legislation In BC, the WCB Compensation for Occupational Disease Policy (WorkSafe BC, 2009) is typically used for short to medium term claims; it acknowledges acute pneumonitis as an occupational disease in Section #29 (Respiratory Diseases), item #29.10 (Acute Respiratory Reactions to Substances with Irritating or Inflammatory Properties) as listed by Schedule B of the Workers Compensation Act (2012). Although this legislation extends to occupational industries where there is exposure to a high concentration of fumes, vapours, gases, mists, or dust of substances that have irritating or inflammatory properties, it also states that in order to be a validated disease respiratory symptoms [must] occur within 48 hours of the exposure (p.41). Lung conditions listed as having sufficient evidence to make a claim are asthma, bronchitis, emphysema, pneumoconiosis, and other specified disease of the lungs. 11 P age

15 However, granulomatous pneumonitis is not covered (p.45) because sufficient evidence to establish this condition as occupational has not been presented. In addition, lifeguard lung symptoms typically emerge long after chronic exposure. CUPE uses both these documents in their claim work, particularly the WCB document for short and medium term claims and Schedule B for when conditions are more permanent and require a pension (personal communication with Tom McKenna, CUPE, September 30, 2012). The Canadian Union for Public Employees (CUPE), BC Municipal Safety Association, BC Recreation and Parks Association (BCRPA), WorkSafe BC, and the Lifesaving Society have developed PoolSafe BC: Best Practices Guide to outline the rights and responsibilities of employers and workers at CUPE pool sites (WorkSafe BC, n.d.). This guide also describes swimming pool hazards, microbiological organisms and their potential effects. This document contains more detailed description of indoor air quality and states: Turnover of air in pools obviously has to happen more often than in the office area. Pool air handling systems need to be designed and calibrated to allow for 4 to 6 air changes per hour. Typical settings are for 50% fresh air being introduced on each air change Watch out for stagnant water and be sure to control water features that generate aerosols (WorkSafe BC, n.d., p.8) 3.2 BC Pool Facility Health and Safety Legislation Scholarly articles on lifeguard lung highlight the need for better ventilation (Sood et al, 2007; Verma et al., 2007). Currently, BC pool health and safety policy and legislation regarding ventilation are unsatisfactory. Most BC legislation addresses water and air quality with a focus on prescribing chemical disinfectants. Unfortunately, MAC are resistant to these chemicals, rendering this legislation insufficient to address lifeguard lung causation. As a result, further 12 Page

16 policy development is required to respond to the growing causal evidence of lifeguard lung. The following sections give an overview of the relevant BC legislation that could address the public health concerns arising from increased diagnosis of lifeguard lung, hot tub lung and related conditions including the BC Pool Regulation 296/2010 (Public Health Act, 2011) and the BC Guidelines for Swimming Pool Operation. The BC Pool Regulation 296/2010 (2011) outlines the minimum standards of safe practice for commercial and public pools within the province and sits at the core of all other pool health and safety guidelines. This regulation requires all public pools to establish their own health and safety plan basic guidelines. Part 3 of the Act outlines operation and maintenance of pools and is specific about design flow rates and keeping water and bathrooms clean, but does not contain legislation on air quality and aerosolization of bacterial agents. Based on the requirement of this regulation, the province and health authorities have created guidelines stipulating pool safety and cleanliness both at the provincial and regional levels in BC. Since ventilation and air quality is not addressed in this act, this policy gap has been translated to other pool operation guidelines. The BC Guidelines for Swimming Pool Operation was recently established in April 2011 and outlines in detail the necessary parameters in which a publicly funded pool in the province should operate (Ministry of Health, 2011). The guidelines include sections on pool water parameters, testing water parameters, chemical testing equipment, records, water clarity, water temperature, water microbiology, ph and alkalinity, chlorine disinfectants, cyanuric acid, ozone, bromine and other chemical measurements and considerations. It also outlines qualifications for maintaining and operating pools in addition to pool safety plans. The pool safety plans include safety protocols for lifeguards, as well as cleanliness, maintenance, and gas chlorine operations. 13 P age

17 However, apart from lifeguard training and staff to bather ratio, there are no further instructions pertaining to health and wellness for lifeguards or other pool staff. The BC Guidelines for Swimming Pool Design, a parallel document to the BC Guidelines for Swimming Pool Operation outlines the need for ventilation for chemicals and to prevent condensation, but mentions nothing about the necessity to reduce exposure of aerosolized microbials. Furthermore, the guidelines mainly pertain to change room areas and general overall facility ventilation; they fail to provide specific recommendations for areas considered most problematic for lifeguard lung and hot tub lung such as the spa, whirlpool, and sauna areas. The five BC respective health authorities produced The Pool Safety Plan: Guide for Pool Operators in January It is based on BC Regulation 296/2010, and it provides instructions for pool operators to develop pool safety guidelines. Section 3 outlines pool and hot tub water maintenance. Similar to the aforementioned guidelines, this focuses on water temperature and chemistry and neglects to describe the need for proper ventilation or any air quality checks. 3.3 Other Regulatory Frameworks With a shortage of legislation preventing the incidence of occupational lifeguard lung in BC, it is worthwhile to see if regulatory frameworks and/or recommendations exist in other jurisdictions. Given that the agents identified in this report (i.e. NTM, MAC and chloramines) are not explicitly addressed in the Canada Management Act and Regulation, guidelines from the US are summarized next. 14 P age

18 3.3.1 United States While the US Centres for Disease Control (CDC) are not directly responsible for monitoring employers compliance with occupational health and safety regulations, they have published recommendations for reducing the incidence of lifeguard lung within indoor pool settings. These suggestions have been put forth by two departments located within the CDC; in addition, standards put forth through the American Society of Heating, Refrigerating and Air- Conditioning Engineers (ASHRAE) are summarized. CDC s National Institute for Occupational Safety and Health (NIOSH) After investigating an outbreak of lifeguard lung symptoms at a large indoor water park, the CDC s National Institute for Occupational Safety and Health (NIOSH) found that lifeguards not only displayed more symptoms than those employees working outside of the enclosed pool area, but that the severity of these symptoms was greater on days where more people used the pool area (NIOSH, 2010). This affirms the idea that the risk for lifeguard lung is greatest when many people are in the pool, as an increased level of nitrogen compounds from sweat and urine introduces higher levels of DBPs for aerosolization. From this investigation, NIOSH identified three overarching recommendations to mitigate the incidence of lifeguard lung within indoor pool settings: 1. Patron and employee education: provide education on identifying symptoms; encourage employees to report symptoms as early as possible 2. Water chemistry considerations: ensure that spray features within indoor pool settings draw water that has been adequately filtered and treated; allow water to drain out of spray features when not in use (e.g. overnight), to reduce amplification of microbials 15 P age

19 3. Ventilation considerations: the supply and return ducts of ventilation systems must be located strategically, to ensure there is enough air movement/removal of contaminants close to aerosolized water features. While the third set of recommendations speak to the importance of adequate ventilation, NIOSH (2010) cautions that ventilation systems must be evaluated on a case- by- case basis. This suggests that a standardized protocol for ventilation design would make it difficult to ascertain whether or not any given system adequately minimizes the risk of both acute and chronic symptoms related to lifeguard lung. CDC s National Centre for Emerging and Zoonotic Infectious Diseases (NCEZID) While NIOSH s recommendations are generalized in nature, the CDC s National Centre for Emerging and Zoonotic Infectious Diseases (NCEZID) has published a brief, internet- based list of recommendations for the prevention of chemical- associated injuries within pool settings. In this list, NCEZID recommends that the air handling system of a pool s chemical storage and pump room be designed so that it is separate from the ventilation of all other areas in a building. In addition, they recommend that ventilation to the pool area be separated from all other areas in the building. NCEZID (2012) also suggests that in the design of pool settings, local building codes and standards published by the American Society of Heating, Refrigerating and Air- Conditioning Engineers (ASHRAE) should be adhered to. Recommendations from ASHRAE are detailed next. American Society of Heating, Refrigerating and Air- Conditioning Engineers Focused on the promotion of energy efficiency, indoor air quality, and sustainability within the industry of heating, refrigeration, and air conditioning systems, ASHRAE has 16 P age

20 numerous standards related to the installation of ventilation systems. As these standards apply to a multitude of settings, their review is beyond the scope of this paper. However, a technical feature published recently in the ASHRAE journal has outlined recommendations for minimizing the impact of disinfectant by- products on those symptoms consistent with lifeguard lung in indoor pool environments (Baxter, 2012). UV radiation, a method to mitigate excessive chlorine levels in pool water, is largely successful in destroying chloramines (Baxter, 2012). However, these systems cannot diminish trichloramines once they are released into the air - unless these are then recirculated into the pool water. Further, UV systems are not designed to address MAC and NTMs in general. With this, Baxter (2012) proposes a source capture and exhaust strategy, where the physical and chemical characteristics of trichloramines are particularly taken advantage of. A diagram of this proposed ventilation system is included in the Appendix, with key points from Baxter (2012) summarized below: 1. As trichloramines have a high vapour density and initially accumulate close to the waterline, pools should exhaust trichloramine vapor at this level, before it can circulate into air of the greater pool environment. 2. To support an additional exhaust system at the waterline, the HVAC system for the general pool environment should be designed to create a gentle air movement across the pool surface (i.e. this must complement and aid the source capture exhaust line). Further, the velocity of this airflow cannot be so great that pool water evaporation and swimmers comfort become a concern (Baxter, 2012). 3. Fresh air (i.e. outdoor air) should replace the trichloramine vapour. 17 P age

21 4.0 Methods for a Risk Assessment An occupational risk assessment is important for employees and employers alike. This process allows employers to mitigate those hazards associated with occupational illness/injury claims and demonstrates employers accountability to its employees. This section of the report applies methodology from the Canadian Centre for Occupational Health and Safety (2009) to address occupational lifeguard lung at the level of individual pools. With this, it is intended that pool staff could apply the steps below to assess the degree to which lifeguard lung poses a risk for staff at their facility. 4.1 Non- carcinogenic Risk Assessment Approach and Methodology 1. Identify hazards of lifeguard lung and their potential for causing lifeguard lung in CUPE employees MAC Air Quality Test - Sample air quality in regular occupational stations of lifeguards and other aquatic staff to ascertain presence of MAC. Sample at the occupational setting at least three separate days, taking care to sample during two high occupancy days and one low occupancy day. The appropriate height at which to sample air is approximately 3 to 4 feet above the pool deck (Centers for Disease Control and Prevention, 2009). The New York State Department of Health (2005) has developed a relevant document, Indoor Air Sampling & Analysis Guidance, which can be referred to if further guidance is required. Water Quality Test - Sample water quality in pool and hot tub for presence of MAC. Following Glazer et al. (2007) methods, collect at least 5 samples to decrease random error in 18 P age

22 sampling measures. Use a 250 ml bottle stood upright under water (approximately 1 foot) to collect samples. Bacteria culturation as per standard laboratory procedures is an adequate tool to assess MAC levels and compare to other levels found in literature. Further specific lab procedures can be found in Glazer et al. (2007). Chloramines Human Behaviour Test - Given that increased levels of chloramines are associated with greater pool use (i.e. high pool occupancy), part of the hazard assessment should include surveying pool users on those behaviours associated with increased levels of nitrogen compounds. Example items should assess the frequencies of both showering before entering the pool and urinating in the pool itself. 2. Rank identified lifeguard lung hazards by importance NTM/MAC have been more recently associated with the disease identified as lifeguard lung (Kahana, Kay, Yakrus, & Waserman, 1997; Lumb et al., 2004), so efforts to eliminate biological agents in pool water or air should be given priority over trichloramine elimination. In the development of new aquatic facilities, however, an attention to building well designed ventilation systems should be given higher priority, as this will mitigate exposure to those biological and chemical causes associated with lifeguard lung. Given that human behaviours lie lower on the hierarchy of controllable hazards, control measures mitigating human byproducts in the pool should be given lower priority. 3. Identify appropriate control measures specific to hazards Based on the hazards identified in the occupational setting, identify the appropriate controls for implementation. For these controls, refer to the list of recommendations provided in this report (see section 6.0: Recommendations for Improvement). 19 P age

23 4. Implement control measures Garner resources (including staff, equipment, funding and support from management) to implement appropriate controls. 5. Evaluate control measures effectiveness Essential to the ongoing improvement of health is the need to critically evaluate the effects of public health actions. Michael Quinn Patton (2008, p.5) describes evaluation as a systematic process, noting its utility is derived from the ability of evaluation to demonstrate an organization s commitment to achieving its stated goals, objectives and outcomes. A population health perspective then recognizes that both program planning and evaluation play an important role in the development of effective interventions, as the latter allows public health professionals to remain cognizant of ongoing and unique population needs (Moyer, Verhouvsek & Wilson, 1997). An essential tool in the process of both planning and evaluation is the logic model. These models, often utilized in the initial steps of program evaluation, provide a conceptual framework to identify how the inputs of a program (in this case, the control measures implemented) are connected to the intended outcomes that an evaluation will then address. A logic model template is included in this report (see Appendix A); for further information on the use of logic models and processes for program evaluation, the W.K. Kellogg Foundation Evaluation Handbook (2005) is both comprehensive and practical in its application. 6. Continue to engage in first five risk assessment steps The process of risk assessment is dynamic in nature, as dominant hazards will vary over time. As research continues to be done, it is important to continually update pool management on leading causes of lifeguard lung and their most effective controls. 20 P age

24 5.0 Strengths and Limitations This report assessment is strengthened by the fact that it brings together the research on lifeguard lung and hot tub lung and considers them under the same umbrella, providing new synthesis of recommendations acknowledging that even if these two conditions are unique, that both can be addressed through similar if not identical environmental risk prevention. Further, this report identifies the need for further investigation of indoor pool lung conditions. This report was also prepared by a group of Public Health Masters students at Simon Fraser University, who had no prior knowledge, experience or vested interest in defending indoor pool employees nor CUPE- thus providing a non- partisan view of the condition. However, there are several limitations of this report that must also be acknowledged: 5.1 Uncertainties in Hazard Assessment Assumptions The literature review completed in preparing this report revealed that there is limited research on the topic of lifeguard and hot tub lung, and the literature that does exist is still not in agreement. The risk assessment methods provided in this report were based solely on an analysis and synthesis of previous research published on lifeguard and hot tub lung, and this report does not represent the work of an original investigation within BC public pool environments. 5.2 Uncertainties in Toxicological Information Researchers generally experience difficulty culturing NTM in the lab (Glazer et al., 2007). In addition, these bacteria are known to cluster in water, making measurements often inaccurate (Glazer et al., 2007). This impacts the validity of associations researchers can make about lifeguard lung incidence and concentrations of NTM. 21 P age

25 5.3 Uncertainties in Exposure Parameters Since lifeguard lung is a condition that can develop over a long period of time, it can be difficult to measure retrospectively the length and intensity of exposure. 5.4 Applicability of ASHRAE Source Capture and Exhaust Strategy The source capture and exhaust strategy proposed by Baxter (2012) is ideal for the conventional pool setting; however, unique applications are possible in those environments with many spray features (such as indoor water parks, or indoor saunas/hot tubs) (See Appendix D). More attention would be required to ascertain where trichloramines initially accumulate in these settings. In addition, this strategy is designed to mitigate those risks posed by trichloramines; it has yet to be validated if such a proposal would also, conceptually, be appropriate for NTM and MAC. 6.0 Recommendations for Improvement Having reviewed the short and long term symptoms associated with indoor swimming pool exposures, the following substitutions and protections - categorized by CUPE s four levels of prevention - can be brought in to protect aquatic workers from being affected by these exposures: 6.1 Prevention & Monitoring at the Source NTM exists in pools and indoor aquatic facilities and is very difficult to remove by chemical or barrier means. Chlorine could be replaced by saltwater chlorination, which would reduce chloramines in the pool water (Beech, Diaz, Ordaz & Palomeque, 1980). However, saltwater chlorination does not eliminate the suspected primary cause of lifeguard lung, 22 P age

26 NTM/MAC. Also, saltwater chlorination is an expensive endeavor due to upkeep costs; this makes it a less feasible option for an economically constrained government. 6.2 Prevention & Monitoring along the Path The source capture and exhaust strategy is a promising method to effectively ventilate trichloramines before they become a part of the general air circulation within indoor pool environments. When designing the HVAC systems, pools and/or facilities should consider having exhaust systems for both trichloramines accumulating at the pool s waterline, as well as for general air circulation in the pool environment. It is also recommended to employ the source capture and exhaust strategy near spray features, should these be a prominent part of a pool s design (See Appendix D). The United States NIOSH (2010) made a similar ventilation recommendation, stating that supply and return ducts should allow a building's ventilation system to provide lots of air movement and constantly be filtering the air and removing contaminants. New building designs should require that spray features draw water that has been filtered and treated thoroughly, tested regularly and always drained from spray features, thus preventing favorable environments for microbials to grow (Rose et al., 1998). NIOSH (2010) has also recommended that spray features produce larger droplets and spray less continuously to reduce aerosolization of both biological and chemical agents. Turnover rates in pools refer to the time it takes for all pool water to pass through the pool filters. Increased turnover rates have been associated with lower levels of NTM in the air (Glazer et al., 2007). Currently, public pools have a mandated maximum turnover of 6 hours (BC Ministry of Health Protection Branch, 2011). Reducing this maximum is a potential strategy for reducing 23 P age

27 risk of lifeguard lung. There are moderate financial and technical requirements involved with this strategy: new filtration systems may have to be purchased and installed if current filtration systems cannot be adjusted to a faster turnover rate. 6.3 Prevention & Monitoring at the Worker level BC Pool Safety Plans identifies worker level protections including masks to be used in the case of emergency chemical spills. While masks may protect the worker from inhaling NTM, they may also interfere with a lifeguard s ability to perform duties, such as drowning prevention communication to swimmers in the pool. Lifeguard lung prevention should not compromise the safety of pool goers, so for this reason, worker level prevention should focus on worker education of the hazard. Following NIOSH (2010) recommendations, worker education should include 1) details on lifeguard lung symptomatology; 2) a declaration of management s full support of the health and safety of its staff to allay their potential concerns about reporting illness at work; 3) the proper method by which staff can report symptoms/illness. 6.4 Prevention & Monitoring at the Business/Administrative level Given the risk for developing lifeguard lung is associated with both the cumulative hours worked in indoor settings and with increased pool occupancy, it is advised that lifeguards shifts be scheduled so the amount of hours spent indoors and/or during times of high pool- use are shared equally among staff. 24 P age

28 To minimize the number of nitrogen compounds contributing to DBPs, it is recommended that staff make announcements (i.e. over a PA system) during pool hours, reminding swimmers to use washrooms when needed. Additionally, instructors should allocate time for bathroom breaks during swimming lessons. Furthermore, current BC pool and hot tub legislation (reviewed in Section 3.0) is not comprehensive enough to prevent occupational lifeguard lung resulting from long- term exposure to airborne hazards. To address lifeguard lung and hot tub lung in the future, existing guidelines and pool policies should be amended to include preventative measures that limit exposure to hazardous airborne pathogens, and improve facility ventilation requirements. 7.0 Conclusion Indoor pools are a valuable recreational resource to British Columbians; it is in the best interest of the public to ensure the continued usability of indoor pools by working to maintain a safe and healthy indoor pool workforce. Lifeguard lung is a serious condition that can have lasting impact on a mostly young aquatic workforce in BC; unhealthy work environments may be related to the high turnover rate seen in the profession. By adopting recommended prevention methods along the pathway, at the worker level, and at the administrative level, pool management can reduce aquatic staff s exposure to lifeguard lung- causing toxicants. Furthermore, management can engage in continual risk assessment and evaluation of control measures in order to keep their approach current and effective. These comprehensive actions have the potential to not only significantly reduce the incidence of lifeguard lung in aquatic staff, but to also foster a healthier workforce in BC. 25 P age

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31 Emanuel, B. P. (1998). The relationship between pool water quality and ventilation. Journal of Environmental Health, 61(2), Retrieved from Falkinham III, J.O. (2003). Mycobacterial aerosols and respiratory disease. Emerging Infectious Diseases, 9(7), Retrieved from /article/9/7/pdfs/ pdf Florentin, A., Hautemanière, A., & Hartemann, P. (2011). Health effects of disinfection byproducts in chlorinated swimming pools. International Journal of Hygiene and Environmental Health, 214(6), Retrieved from Glazer, C. S., Martyny, J. W., Lee, B., Sanchez, T. L., Sells, T. M., Newman, L. S.,... Rose, C. S. (2007). Nontuberculous mycobacteria in aerosol droplets and bulk water samples from therapy pools and hot tubs. Journal of Occupational and Environmental Hygiene, 4(11), doi: / Hanak, V., Sanjay, K., Aksamit, H. D., Thomas, T. H., Henry, D., T., Ryu, J. H. (2006) Hot tub lung: Presenting features and clinical course of 21 patients. Respiratory Medicine, 100: Hartman, T. E., Jensen, E., Tazelaar, H. D., Hanak, V., & Ryu, J. H. (2007). CT findings of granulomatous pneumonitis secondary to mycobacterium avium-intracellulare inhalation: "hot tub lung". American Journal of Roentgenology, 188(4), Retrieved from 28 P age

32 Jacobs, J. H., Spaan, S., Rooy, G. B. G. J., Meliefste, C., Zaat, V. A. C., Rooyackers, J. M., & Heederik, D. (2007). Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers. European Respiratory Journal, 29(4), Retrieved from m/ Kahana, L. M., Kay, J. M., Yakrus, M. A., & Waserman, S. (1997). Mycobacterium avium complex infection in an immunocompetent young adult related to hot tub exposure. Chest, 111(1), Retrieved from Lumb, R., Stapledon, R., Scroop, A., Bond, P., Cunliffe, D., Goodwin, A.,... Bastian, I. (2004). Investigation of spa pools associated with lung disorders caused by mycobacterium avium complex in immunocompetent adults. Applied and Environmental Microbiology, 70(8), Retrieved from Massin, N., Bohadana, A. B., Wild, P., Héry, M., Toamain, J. P., & Hubert, G. (1998). Respiratory symptoms and bronchial responsiveness in lifeguards exposed to nitrogen trichloride in indoor swimming pools. Occupational and Environmental Medicine, 55(4), Retrieved from Moreno, M.A., Furtner, F., & Rivara, F.P. (2009). Water safety and swimming lessons for children. Archives of Pediatrics & Adolescent Medicine, 163(3): 288. doi: doi: /archpediatrics Moyer, A., Verhovsek, H. & Wilson, V.L. (1997). Facilitating the shift to population-based public health programs: Innovation through the use of framework and logic model tools. Canadian Journal of Public Health, 88(2), P age

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35 Workers Compensation Act (2012). Retrieved November 9, 2012 from: WorkSafe BC. (2011). Section 1: Why focus on young workers? Retrieved from FocusReport2011.asp?reportID=36329 WorkSafe BC. (2009). Chapter 4: Compensation for occupational disease. Retrieved November 1, 2012 from, aims_manual/volume_ii/assets/pdf/rscm_ii_04.pdf WorkSafe BC. (n.d.). Pool safe BC best practices guide. Retrieved from bc.com/publications/publication_index/p.asp 32 P age

36 APPENDICES A. Logic Model Template B. Glossary of Terms C. Abbreviations D. Pictures and Illustrations i P age

37 APPENDIX A: Logic Model Template Resources Activities Outputs Short- & Long- Term Outcomes In order to In order to Once these We expect that if accomplish address activities are accomplished control occupational accomplished, the these activities measure lifeguard lung the following effects will lead to the activities, the following activities will occur in the following following should be occupational pool changes in 1-3 resources are accomplished: setting: then 4-6 years: required: Impact We expect that if accomplished these activities will lead to the following changes in 7-10 years: (Logic Model template adapted from W.K. Kellogg Foundation, 2004) ii P age

38 APPENDIX B: Glossary of Terms Aerosolized water water broken down into small enough molecules to be carried in the air Chloramines the end product of a reaction between chlorine and nitrogenous material (sweat and urine) Endotoxin- lipopolysaccharides in the wall of gram-negative bacteria that have the potential to cause toxicity Granulomatous pneumonitis alveoli inflammation within the lung; formation of granulomas (macrophages) Hypersensitivity pneumonitis general alveoli inflammation within the lung granulomas not necessarily present Nontuberculous Mycobacteria environmental bacteria that is causally linked with lifeguard lung Occupational lifeguard lung granulomatous/hypersensitivity pneumonitis Outbreak incident cases of disease in a short time period well above regular or seasonal numbers Risk assessment a systematic approach to identifying hazards and reducing exposure to such hazards by implementing controls Trichloramine a volatile chloramine, most likely to vaporize out of all chloramines in pool water Zoonotic Infectious Diseases infectious diseases transferred from one species to another iii P age

39 APPENDIX C: Abbreviations AIDS Acquired Immunodeficiency Syndrome ASHRAE American Society of Heating, Refrigerating and Air-Conditioning Engineers CDC Centres for Disease Control CUPE DBP Canadian Union of Public Employees Disinfectant By-Products HP MAC NCEZID Hypersensitivity Pneumonitis Mycobacterium Avium Complex National Centre for Emerging and Zoonotic Infectious Diseases NCl 3 NIOSH NTM WCA Trichloramine National Institute for Occupational Safety and Health Nontuberculous Mycobacteria Workers Compensation Act WCB Workers Compensation Board iv P age

40 APPENDIX D: Pictures and Illustrations Image: The source capture and exhaust strategy (Baxter, 2012) v P age

41 Image: Example of ventilation closer to the source to reduce aerosolization of causal agents of lifeguard lung vi P age