Investigation of Employee Symptoms at an Indoor Waterpark
Transcript of Investigation of Employee Symptoms at an Indoor Waterpark
Investigation of Employee Symptoms at an Indoor Waterpark Lilia Chen MS Bich Dang MD Charles Mueller MS Kevin H Dunn MS CIH Daniel Almaguer MS Jennifer L Ernst BS Charles S Otto III MPS RS
Health Hazard Evaluation Report HETA 2007-0163-3062 Great Wolf Lodge Mason Ohio June 2008
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention
WorkplaceSafety and Health
National Institute for Occupational Safety and Health
The employer shall post a copy of this report for a period of 30 calendar days at or near the workplace(s) of affected employees The employer shall take steps to insure that the posted determinations are not altered defaced or covered by other material during such period [37 FR 23640 November 7 1972 as amended at 45 FR 2653 January 14 1980]
Contents
RepoRt Abbreviations ii
HighlightsoftheNIOSHHealthHazardEvaluation iv
Summary vi
Introduction1
Assessment7
Results11
Discussion19
Conclusions30
Recommendations31
References33
Appendix A Tables37
Appendix B Methods41
Appendix C OccupationalExposureLimitsandHealthEffects44
ACknowledgements AcknowledgementsandAvailabilityofReport52
Health Hazard Evaluation Report 2007-0163-3062 Page
ABBReviAtions
ACGIHreg AmericanConferenceofGovernmentalIndustrialHygienists ACH Airchangesperhour ASHRAE AmericanSocietyofHeatingRefrigeratingandAirConditioningEngineers ANSI AmericanNationalStandardsInstitute CDC CentersforDiseaseControlandPrevention CFD Computationalfluiddynamics cfm Cubicfeetperminute cm Centimeter DBP Disinfectionby-products DIN DeutschesInstitutfuumlrNormungeV(GermanInstituteforStandardization) DPD NNdiethyl-p-phenylenediamine EU Endotoxinunit ft Feet gL Gramsperliter GWL GreatWolfLodge HVAC Heatingventilatingandairconditioning INRS InstitutNationaldeRechercheetdeSecurite(NationalInstituteofResearchandSafety) LAL Limulusamoebocytelysate LOD Limitofdetection LOQ Limitofquantitation mgL Milligramsperliter mgm3 Milligramspercubicmeter mL Milliliter mj Millijoule mm Millimeter NAICS NorthAmericanIndustryClassificationSystem NCEH NationalCenterforEnvironmentalHealth NIOSH NationalInstituteforOccupationalSafetyandHealth no Number OEL Occupationalexposurelimit OSHA OccupationalSafetyandHealthAdministration PBZ Personalbreathing-zone PEL Permissibleexposurelimit ppm Partspermillion REL Recommendedexposurelimit RH Relativehumidity RLV Relativelimitvalue SQRT Squareroot STEL Shorttermexposurelimit TLVreg Thresholdlimitvalue TWA Time-weightedaverage microg Microgram
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ABBReviAtions (Continued)
microm Micrometer UV Ultraviolet WCCHD WarrenCountyCombinedHealthDistrict WEEL Workplaceenvironmentalexposurelevel WHO WorldHealthOrganization
Health Hazard Evaluation Report 2007-0163-3062 Page
HigHligHts of tHe
niosH HeAltH
HAzARd evAluAtion
The Warren County Combined Health District asked the National Institute for Occupational Safety and Health (NIOSH) to assist in investigating the cause of symptoms reported at the Great Wolf Lodge (GWL) indoor waterpark resort in Mason Ohio Symptoms included cough wheezing shortness of breath eye and nose irritation and skin rashes We conducted our investigation in March and April 2007
What NIOSH Did Wetestedtheairfortrichloraminesolublechlorine
compoundsandendotoxin
WetestedthewaterforfecalcontaminationLegionella mycobacteriaendotoxinsulfitesandsulfates
Wecheckedthewaterchemistryandreviewedthewater systemdesign
WeadministeredquestionnairestoGWLemployeesabout theirhealth
Wereviewedtheventilationsystemdesign
What NIOSH Found Wefoundtrichloramineconcentrationssimilartolevels
foundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritation
Wefoundairendotoxinconcentrationsatlevelsthathave beenassociatedwithcoughandfever
WedidnotfindfecalcontaminationLegionella mycobacteriasulfitesorsulfatesinthepoolwater
WefoundthatwaterchemistryresultsmetOhiostate standards
Wefoundthatlifeguardshadmorework-relatedsymptoms thanemployeesnotworkinginsidetheindoorpoolarea
Wefoundthatlifeguardshadmorework-relatedcoughand eyeirritationondayswhenthenumberofpeopleusingthe indoorpoolareawashigh
Wefoundthattheventilationsystemdesignmaynotprovide adequateairmovementanddistribution
What Managers Can Do Managersshouldfurtherassesstheventilationsystem
toensureenoughairmovementandproperremovalof contaminants
Managersshouldconsiderreducingwaterattractioncycle timesandusinglargerdropletdischargenozzlestoreduce aerosolizationofcontaminants
Managersshouldconsiderredesigningthesprayfeature pipingsystemtomakesurethatwaterusedinthepoolsis takendirectlyafterthefiltrationandtreatmentcycle
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HigHligHts of tHe Managersshouldmonitoranddocumentanysymptoms niosH HeAltH reportedbyemployeesandpatrons
HAzARd evAluAtion What Employees Can Do(Continued) Employeesshouldreportanysymptomsthatmaybework-
relatedtotheirsupervisors
Health Hazard Evaluation Report 2007-0163-3062 Page v
summARy
Lifeguards had significantly more work-related symptoms than employees who did not work in the indoor pool area they had more symptoms on days when hotel occupancy was high We found airborne chloramines and endotoxin which may have contributed to reported symptoms We recommend evaluating the ventilation system design to identify ways to increase air movement and reduce air contaminant levels at the pool deck level
InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedrespiratorysymptomseyeand noseirritationandskinrashes
InMarch2007wevisitedthesiteforthefirsttimeWemetwith managementWCCHDrepresentativesandanemployeelifeguard representativetouredthefacilityandinterviewedworkersina privatesetting
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredairtemperatureandRHandadministered questionnairestoemployeesregardingmedicaljobandpersonal historyandwork-relatedsymptomsWaterchemistrytestswere performedandwatersampleswerecollectedforLegionellafecal coliformbacteriamycobacteriaendotoxinsulfitesandsulfates Areviewwasconductedofthewatersystemandventilationsystem designs Thetrichloramineconcentrationswemeasuredweresimilarto thosefoundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritationAir endotoxinlevelsinallpoolareasexceptthewaterfortexceeded theACGIHproposedRLVforendotoxinexposure(10times thebackgroundlevelwhensymptomsconsistentwithendotoxin exposurearereported)WaterchemistryresultsmetOhiostate standardsNoLegionellamycobacteriaorfecalcoliformbacteria werefoundinanyofthewatersamplescollected
Lifeguardshadsignificantlymorework-relatedrespiratory symptomseyeandnoseirritationfeverbodyachesandskin rashesinthe4weekspriortoquestionnairecompletionthan employeeswhodidnotworkintheindoorpoolareaThe prevalenceofwork-relatedcoughandeyeirritationamongthe lifeguardswassignificantlyhigherondayswhenhoteloccupancy washigh
Ventilationdesignconcernsincludetheplacementofairsupply diffusersandreturnairinletsatheightsof30ndash80ftabovedeck levelThisheightmakesitdifficulttoprovideadequateair movementandmixingatthepoolsurfaceanddecklevelsand createsthepotentialforshortcircuitingofsupplyairtoexhaust
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summARy(Continued) Thisreportcontainsrecommendationsfordecreasingthe
chloramineexposuresthoughttocausethereportedsymptoms includingmodificationandredesignoftheventilationsystemto increaseairmovementatthepooldecklevel
Keywords NAICS 713990 (All Other Amusement and Recreation Industries) chloramines trichloramine nitrogen trichloride indoor waterpark pools hot tubs spas sulfates sulfites endotoxin fecal coliform relative humidity Legionella mycobacteria cough respiratory symptoms rash eye irritation
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Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
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intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
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intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
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intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
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Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
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Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
The employer shall post a copy of this report for a period of 30 calendar days at or near the workplace(s) of affected employees The employer shall take steps to insure that the posted determinations are not altered defaced or covered by other material during such period [37 FR 23640 November 7 1972 as amended at 45 FR 2653 January 14 1980]
Contents
RepoRt Abbreviations ii
HighlightsoftheNIOSHHealthHazardEvaluation iv
Summary vi
Introduction1
Assessment7
Results11
Discussion19
Conclusions30
Recommendations31
References33
Appendix A Tables37
Appendix B Methods41
Appendix C OccupationalExposureLimitsandHealthEffects44
ACknowledgements AcknowledgementsandAvailabilityofReport52
Health Hazard Evaluation Report 2007-0163-3062 Page
ABBReviAtions
ACGIHreg AmericanConferenceofGovernmentalIndustrialHygienists ACH Airchangesperhour ASHRAE AmericanSocietyofHeatingRefrigeratingandAirConditioningEngineers ANSI AmericanNationalStandardsInstitute CDC CentersforDiseaseControlandPrevention CFD Computationalfluiddynamics cfm Cubicfeetperminute cm Centimeter DBP Disinfectionby-products DIN DeutschesInstitutfuumlrNormungeV(GermanInstituteforStandardization) DPD NNdiethyl-p-phenylenediamine EU Endotoxinunit ft Feet gL Gramsperliter GWL GreatWolfLodge HVAC Heatingventilatingandairconditioning INRS InstitutNationaldeRechercheetdeSecurite(NationalInstituteofResearchandSafety) LAL Limulusamoebocytelysate LOD Limitofdetection LOQ Limitofquantitation mgL Milligramsperliter mgm3 Milligramspercubicmeter mL Milliliter mj Millijoule mm Millimeter NAICS NorthAmericanIndustryClassificationSystem NCEH NationalCenterforEnvironmentalHealth NIOSH NationalInstituteforOccupationalSafetyandHealth no Number OEL Occupationalexposurelimit OSHA OccupationalSafetyandHealthAdministration PBZ Personalbreathing-zone PEL Permissibleexposurelimit ppm Partspermillion REL Recommendedexposurelimit RH Relativehumidity RLV Relativelimitvalue SQRT Squareroot STEL Shorttermexposurelimit TLVreg Thresholdlimitvalue TWA Time-weightedaverage microg Microgram
Page Health Hazard Evaluation Report 2007-0163-3062
ABBReviAtions (Continued)
microm Micrometer UV Ultraviolet WCCHD WarrenCountyCombinedHealthDistrict WEEL Workplaceenvironmentalexposurelevel WHO WorldHealthOrganization
Health Hazard Evaluation Report 2007-0163-3062 Page
HigHligHts of tHe
niosH HeAltH
HAzARd evAluAtion
The Warren County Combined Health District asked the National Institute for Occupational Safety and Health (NIOSH) to assist in investigating the cause of symptoms reported at the Great Wolf Lodge (GWL) indoor waterpark resort in Mason Ohio Symptoms included cough wheezing shortness of breath eye and nose irritation and skin rashes We conducted our investigation in March and April 2007
What NIOSH Did Wetestedtheairfortrichloraminesolublechlorine
compoundsandendotoxin
WetestedthewaterforfecalcontaminationLegionella mycobacteriaendotoxinsulfitesandsulfates
Wecheckedthewaterchemistryandreviewedthewater systemdesign
WeadministeredquestionnairestoGWLemployeesabout theirhealth
Wereviewedtheventilationsystemdesign
What NIOSH Found Wefoundtrichloramineconcentrationssimilartolevels
foundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritation
Wefoundairendotoxinconcentrationsatlevelsthathave beenassociatedwithcoughandfever
WedidnotfindfecalcontaminationLegionella mycobacteriasulfitesorsulfatesinthepoolwater
WefoundthatwaterchemistryresultsmetOhiostate standards
Wefoundthatlifeguardshadmorework-relatedsymptoms thanemployeesnotworkinginsidetheindoorpoolarea
Wefoundthatlifeguardshadmorework-relatedcoughand eyeirritationondayswhenthenumberofpeopleusingthe indoorpoolareawashigh
Wefoundthattheventilationsystemdesignmaynotprovide adequateairmovementanddistribution
What Managers Can Do Managersshouldfurtherassesstheventilationsystem
toensureenoughairmovementandproperremovalof contaminants
Managersshouldconsiderreducingwaterattractioncycle timesandusinglargerdropletdischargenozzlestoreduce aerosolizationofcontaminants
Managersshouldconsiderredesigningthesprayfeature pipingsystemtomakesurethatwaterusedinthepoolsis takendirectlyafterthefiltrationandtreatmentcycle
Page v Health Hazard Evaluation Report 2007-0163-3062
HigHligHts of tHe Managersshouldmonitoranddocumentanysymptoms niosH HeAltH reportedbyemployeesandpatrons
HAzARd evAluAtion What Employees Can Do(Continued) Employeesshouldreportanysymptomsthatmaybework-
relatedtotheirsupervisors
Health Hazard Evaluation Report 2007-0163-3062 Page v
summARy
Lifeguards had significantly more work-related symptoms than employees who did not work in the indoor pool area they had more symptoms on days when hotel occupancy was high We found airborne chloramines and endotoxin which may have contributed to reported symptoms We recommend evaluating the ventilation system design to identify ways to increase air movement and reduce air contaminant levels at the pool deck level
InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedrespiratorysymptomseyeand noseirritationandskinrashes
InMarch2007wevisitedthesiteforthefirsttimeWemetwith managementWCCHDrepresentativesandanemployeelifeguard representativetouredthefacilityandinterviewedworkersina privatesetting
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredairtemperatureandRHandadministered questionnairestoemployeesregardingmedicaljobandpersonal historyandwork-relatedsymptomsWaterchemistrytestswere performedandwatersampleswerecollectedforLegionellafecal coliformbacteriamycobacteriaendotoxinsulfitesandsulfates Areviewwasconductedofthewatersystemandventilationsystem designs Thetrichloramineconcentrationswemeasuredweresimilarto thosefoundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritationAir endotoxinlevelsinallpoolareasexceptthewaterfortexceeded theACGIHproposedRLVforendotoxinexposure(10times thebackgroundlevelwhensymptomsconsistentwithendotoxin exposurearereported)WaterchemistryresultsmetOhiostate standardsNoLegionellamycobacteriaorfecalcoliformbacteria werefoundinanyofthewatersamplescollected
Lifeguardshadsignificantlymorework-relatedrespiratory symptomseyeandnoseirritationfeverbodyachesandskin rashesinthe4weekspriortoquestionnairecompletionthan employeeswhodidnotworkintheindoorpoolareaThe prevalenceofwork-relatedcoughandeyeirritationamongthe lifeguardswassignificantlyhigherondayswhenhoteloccupancy washigh
Ventilationdesignconcernsincludetheplacementofairsupply diffusersandreturnairinletsatheightsof30ndash80ftabovedeck levelThisheightmakesitdifficulttoprovideadequateair movementandmixingatthepoolsurfaceanddecklevelsand createsthepotentialforshortcircuitingofsupplyairtoexhaust
Page v Health Hazard Evaluation Report 2007-0163-3062
summARy(Continued) Thisreportcontainsrecommendationsfordecreasingthe
chloramineexposuresthoughttocausethereportedsymptoms includingmodificationandredesignoftheventilationsystemto increaseairmovementatthepooldecklevel
Keywords NAICS 713990 (All Other Amusement and Recreation Industries) chloramines trichloramine nitrogen trichloride indoor waterpark pools hot tubs spas sulfates sulfites endotoxin fecal coliform relative humidity Legionella mycobacteria cough respiratory symptoms rash eye irritation
Health Hazard Evaluation Report 2007-0163-3062 Page v
Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Contents
RepoRt Abbreviations ii
HighlightsoftheNIOSHHealthHazardEvaluation iv
Summary vi
Introduction1
Assessment7
Results11
Discussion19
Conclusions30
Recommendations31
References33
Appendix A Tables37
Appendix B Methods41
Appendix C OccupationalExposureLimitsandHealthEffects44
ACknowledgements AcknowledgementsandAvailabilityofReport52
Health Hazard Evaluation Report 2007-0163-3062 Page
ABBReviAtions
ACGIHreg AmericanConferenceofGovernmentalIndustrialHygienists ACH Airchangesperhour ASHRAE AmericanSocietyofHeatingRefrigeratingandAirConditioningEngineers ANSI AmericanNationalStandardsInstitute CDC CentersforDiseaseControlandPrevention CFD Computationalfluiddynamics cfm Cubicfeetperminute cm Centimeter DBP Disinfectionby-products DIN DeutschesInstitutfuumlrNormungeV(GermanInstituteforStandardization) DPD NNdiethyl-p-phenylenediamine EU Endotoxinunit ft Feet gL Gramsperliter GWL GreatWolfLodge HVAC Heatingventilatingandairconditioning INRS InstitutNationaldeRechercheetdeSecurite(NationalInstituteofResearchandSafety) LAL Limulusamoebocytelysate LOD Limitofdetection LOQ Limitofquantitation mgL Milligramsperliter mgm3 Milligramspercubicmeter mL Milliliter mj Millijoule mm Millimeter NAICS NorthAmericanIndustryClassificationSystem NCEH NationalCenterforEnvironmentalHealth NIOSH NationalInstituteforOccupationalSafetyandHealth no Number OEL Occupationalexposurelimit OSHA OccupationalSafetyandHealthAdministration PBZ Personalbreathing-zone PEL Permissibleexposurelimit ppm Partspermillion REL Recommendedexposurelimit RH Relativehumidity RLV Relativelimitvalue SQRT Squareroot STEL Shorttermexposurelimit TLVreg Thresholdlimitvalue TWA Time-weightedaverage microg Microgram
Page Health Hazard Evaluation Report 2007-0163-3062
ABBReviAtions (Continued)
microm Micrometer UV Ultraviolet WCCHD WarrenCountyCombinedHealthDistrict WEEL Workplaceenvironmentalexposurelevel WHO WorldHealthOrganization
Health Hazard Evaluation Report 2007-0163-3062 Page
HigHligHts of tHe
niosH HeAltH
HAzARd evAluAtion
The Warren County Combined Health District asked the National Institute for Occupational Safety and Health (NIOSH) to assist in investigating the cause of symptoms reported at the Great Wolf Lodge (GWL) indoor waterpark resort in Mason Ohio Symptoms included cough wheezing shortness of breath eye and nose irritation and skin rashes We conducted our investigation in March and April 2007
What NIOSH Did Wetestedtheairfortrichloraminesolublechlorine
compoundsandendotoxin
WetestedthewaterforfecalcontaminationLegionella mycobacteriaendotoxinsulfitesandsulfates
Wecheckedthewaterchemistryandreviewedthewater systemdesign
WeadministeredquestionnairestoGWLemployeesabout theirhealth
Wereviewedtheventilationsystemdesign
What NIOSH Found Wefoundtrichloramineconcentrationssimilartolevels
foundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritation
Wefoundairendotoxinconcentrationsatlevelsthathave beenassociatedwithcoughandfever
WedidnotfindfecalcontaminationLegionella mycobacteriasulfitesorsulfatesinthepoolwater
WefoundthatwaterchemistryresultsmetOhiostate standards
Wefoundthatlifeguardshadmorework-relatedsymptoms thanemployeesnotworkinginsidetheindoorpoolarea
Wefoundthatlifeguardshadmorework-relatedcoughand eyeirritationondayswhenthenumberofpeopleusingthe indoorpoolareawashigh
Wefoundthattheventilationsystemdesignmaynotprovide adequateairmovementanddistribution
What Managers Can Do Managersshouldfurtherassesstheventilationsystem
toensureenoughairmovementandproperremovalof contaminants
Managersshouldconsiderreducingwaterattractioncycle timesandusinglargerdropletdischargenozzlestoreduce aerosolizationofcontaminants
Managersshouldconsiderredesigningthesprayfeature pipingsystemtomakesurethatwaterusedinthepoolsis takendirectlyafterthefiltrationandtreatmentcycle
Page v Health Hazard Evaluation Report 2007-0163-3062
HigHligHts of tHe Managersshouldmonitoranddocumentanysymptoms niosH HeAltH reportedbyemployeesandpatrons
HAzARd evAluAtion What Employees Can Do(Continued) Employeesshouldreportanysymptomsthatmaybework-
relatedtotheirsupervisors
Health Hazard Evaluation Report 2007-0163-3062 Page v
summARy
Lifeguards had significantly more work-related symptoms than employees who did not work in the indoor pool area they had more symptoms on days when hotel occupancy was high We found airborne chloramines and endotoxin which may have contributed to reported symptoms We recommend evaluating the ventilation system design to identify ways to increase air movement and reduce air contaminant levels at the pool deck level
InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedrespiratorysymptomseyeand noseirritationandskinrashes
InMarch2007wevisitedthesiteforthefirsttimeWemetwith managementWCCHDrepresentativesandanemployeelifeguard representativetouredthefacilityandinterviewedworkersina privatesetting
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredairtemperatureandRHandadministered questionnairestoemployeesregardingmedicaljobandpersonal historyandwork-relatedsymptomsWaterchemistrytestswere performedandwatersampleswerecollectedforLegionellafecal coliformbacteriamycobacteriaendotoxinsulfitesandsulfates Areviewwasconductedofthewatersystemandventilationsystem designs Thetrichloramineconcentrationswemeasuredweresimilarto thosefoundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritationAir endotoxinlevelsinallpoolareasexceptthewaterfortexceeded theACGIHproposedRLVforendotoxinexposure(10times thebackgroundlevelwhensymptomsconsistentwithendotoxin exposurearereported)WaterchemistryresultsmetOhiostate standardsNoLegionellamycobacteriaorfecalcoliformbacteria werefoundinanyofthewatersamplescollected
Lifeguardshadsignificantlymorework-relatedrespiratory symptomseyeandnoseirritationfeverbodyachesandskin rashesinthe4weekspriortoquestionnairecompletionthan employeeswhodidnotworkintheindoorpoolareaThe prevalenceofwork-relatedcoughandeyeirritationamongthe lifeguardswassignificantlyhigherondayswhenhoteloccupancy washigh
Ventilationdesignconcernsincludetheplacementofairsupply diffusersandreturnairinletsatheightsof30ndash80ftabovedeck levelThisheightmakesitdifficulttoprovideadequateair movementandmixingatthepoolsurfaceanddecklevelsand createsthepotentialforshortcircuitingofsupplyairtoexhaust
Page v Health Hazard Evaluation Report 2007-0163-3062
summARy(Continued) Thisreportcontainsrecommendationsfordecreasingthe
chloramineexposuresthoughttocausethereportedsymptoms includingmodificationandredesignoftheventilationsystemto increaseairmovementatthepooldecklevel
Keywords NAICS 713990 (All Other Amusement and Recreation Industries) chloramines trichloramine nitrogen trichloride indoor waterpark pools hot tubs spas sulfates sulfites endotoxin fecal coliform relative humidity Legionella mycobacteria cough respiratory symptoms rash eye irritation
Health Hazard Evaluation Report 2007-0163-3062 Page v
Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
ABBReviAtions
ACGIHreg AmericanConferenceofGovernmentalIndustrialHygienists ACH Airchangesperhour ASHRAE AmericanSocietyofHeatingRefrigeratingandAirConditioningEngineers ANSI AmericanNationalStandardsInstitute CDC CentersforDiseaseControlandPrevention CFD Computationalfluiddynamics cfm Cubicfeetperminute cm Centimeter DBP Disinfectionby-products DIN DeutschesInstitutfuumlrNormungeV(GermanInstituteforStandardization) DPD NNdiethyl-p-phenylenediamine EU Endotoxinunit ft Feet gL Gramsperliter GWL GreatWolfLodge HVAC Heatingventilatingandairconditioning INRS InstitutNationaldeRechercheetdeSecurite(NationalInstituteofResearchandSafety) LAL Limulusamoebocytelysate LOD Limitofdetection LOQ Limitofquantitation mgL Milligramsperliter mgm3 Milligramspercubicmeter mL Milliliter mj Millijoule mm Millimeter NAICS NorthAmericanIndustryClassificationSystem NCEH NationalCenterforEnvironmentalHealth NIOSH NationalInstituteforOccupationalSafetyandHealth no Number OEL Occupationalexposurelimit OSHA OccupationalSafetyandHealthAdministration PBZ Personalbreathing-zone PEL Permissibleexposurelimit ppm Partspermillion REL Recommendedexposurelimit RH Relativehumidity RLV Relativelimitvalue SQRT Squareroot STEL Shorttermexposurelimit TLVreg Thresholdlimitvalue TWA Time-weightedaverage microg Microgram
Page Health Hazard Evaluation Report 2007-0163-3062
ABBReviAtions (Continued)
microm Micrometer UV Ultraviolet WCCHD WarrenCountyCombinedHealthDistrict WEEL Workplaceenvironmentalexposurelevel WHO WorldHealthOrganization
Health Hazard Evaluation Report 2007-0163-3062 Page
HigHligHts of tHe
niosH HeAltH
HAzARd evAluAtion
The Warren County Combined Health District asked the National Institute for Occupational Safety and Health (NIOSH) to assist in investigating the cause of symptoms reported at the Great Wolf Lodge (GWL) indoor waterpark resort in Mason Ohio Symptoms included cough wheezing shortness of breath eye and nose irritation and skin rashes We conducted our investigation in March and April 2007
What NIOSH Did Wetestedtheairfortrichloraminesolublechlorine
compoundsandendotoxin
WetestedthewaterforfecalcontaminationLegionella mycobacteriaendotoxinsulfitesandsulfates
Wecheckedthewaterchemistryandreviewedthewater systemdesign
WeadministeredquestionnairestoGWLemployeesabout theirhealth
Wereviewedtheventilationsystemdesign
What NIOSH Found Wefoundtrichloramineconcentrationssimilartolevels
foundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritation
Wefoundairendotoxinconcentrationsatlevelsthathave beenassociatedwithcoughandfever
WedidnotfindfecalcontaminationLegionella mycobacteriasulfitesorsulfatesinthepoolwater
WefoundthatwaterchemistryresultsmetOhiostate standards
Wefoundthatlifeguardshadmorework-relatedsymptoms thanemployeesnotworkinginsidetheindoorpoolarea
Wefoundthatlifeguardshadmorework-relatedcoughand eyeirritationondayswhenthenumberofpeopleusingthe indoorpoolareawashigh
Wefoundthattheventilationsystemdesignmaynotprovide adequateairmovementanddistribution
What Managers Can Do Managersshouldfurtherassesstheventilationsystem
toensureenoughairmovementandproperremovalof contaminants
Managersshouldconsiderreducingwaterattractioncycle timesandusinglargerdropletdischargenozzlestoreduce aerosolizationofcontaminants
Managersshouldconsiderredesigningthesprayfeature pipingsystemtomakesurethatwaterusedinthepoolsis takendirectlyafterthefiltrationandtreatmentcycle
Page v Health Hazard Evaluation Report 2007-0163-3062
HigHligHts of tHe Managersshouldmonitoranddocumentanysymptoms niosH HeAltH reportedbyemployeesandpatrons
HAzARd evAluAtion What Employees Can Do(Continued) Employeesshouldreportanysymptomsthatmaybework-
relatedtotheirsupervisors
Health Hazard Evaluation Report 2007-0163-3062 Page v
summARy
Lifeguards had significantly more work-related symptoms than employees who did not work in the indoor pool area they had more symptoms on days when hotel occupancy was high We found airborne chloramines and endotoxin which may have contributed to reported symptoms We recommend evaluating the ventilation system design to identify ways to increase air movement and reduce air contaminant levels at the pool deck level
InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedrespiratorysymptomseyeand noseirritationandskinrashes
InMarch2007wevisitedthesiteforthefirsttimeWemetwith managementWCCHDrepresentativesandanemployeelifeguard representativetouredthefacilityandinterviewedworkersina privatesetting
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredairtemperatureandRHandadministered questionnairestoemployeesregardingmedicaljobandpersonal historyandwork-relatedsymptomsWaterchemistrytestswere performedandwatersampleswerecollectedforLegionellafecal coliformbacteriamycobacteriaendotoxinsulfitesandsulfates Areviewwasconductedofthewatersystemandventilationsystem designs Thetrichloramineconcentrationswemeasuredweresimilarto thosefoundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritationAir endotoxinlevelsinallpoolareasexceptthewaterfortexceeded theACGIHproposedRLVforendotoxinexposure(10times thebackgroundlevelwhensymptomsconsistentwithendotoxin exposurearereported)WaterchemistryresultsmetOhiostate standardsNoLegionellamycobacteriaorfecalcoliformbacteria werefoundinanyofthewatersamplescollected
Lifeguardshadsignificantlymorework-relatedrespiratory symptomseyeandnoseirritationfeverbodyachesandskin rashesinthe4weekspriortoquestionnairecompletionthan employeeswhodidnotworkintheindoorpoolareaThe prevalenceofwork-relatedcoughandeyeirritationamongthe lifeguardswassignificantlyhigherondayswhenhoteloccupancy washigh
Ventilationdesignconcernsincludetheplacementofairsupply diffusersandreturnairinletsatheightsof30ndash80ftabovedeck levelThisheightmakesitdifficulttoprovideadequateair movementandmixingatthepoolsurfaceanddecklevelsand createsthepotentialforshortcircuitingofsupplyairtoexhaust
Page v Health Hazard Evaluation Report 2007-0163-3062
summARy(Continued) Thisreportcontainsrecommendationsfordecreasingthe
chloramineexposuresthoughttocausethereportedsymptoms includingmodificationandredesignoftheventilationsystemto increaseairmovementatthepooldecklevel
Keywords NAICS 713990 (All Other Amusement and Recreation Industries) chloramines trichloramine nitrogen trichloride indoor waterpark pools hot tubs spas sulfates sulfites endotoxin fecal coliform relative humidity Legionella mycobacteria cough respiratory symptoms rash eye irritation
Health Hazard Evaluation Report 2007-0163-3062 Page v
Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
ABBReviAtions (Continued)
microm Micrometer UV Ultraviolet WCCHD WarrenCountyCombinedHealthDistrict WEEL Workplaceenvironmentalexposurelevel WHO WorldHealthOrganization
Health Hazard Evaluation Report 2007-0163-3062 Page
HigHligHts of tHe
niosH HeAltH
HAzARd evAluAtion
The Warren County Combined Health District asked the National Institute for Occupational Safety and Health (NIOSH) to assist in investigating the cause of symptoms reported at the Great Wolf Lodge (GWL) indoor waterpark resort in Mason Ohio Symptoms included cough wheezing shortness of breath eye and nose irritation and skin rashes We conducted our investigation in March and April 2007
What NIOSH Did Wetestedtheairfortrichloraminesolublechlorine
compoundsandendotoxin
WetestedthewaterforfecalcontaminationLegionella mycobacteriaendotoxinsulfitesandsulfates
Wecheckedthewaterchemistryandreviewedthewater systemdesign
WeadministeredquestionnairestoGWLemployeesabout theirhealth
Wereviewedtheventilationsystemdesign
What NIOSH Found Wefoundtrichloramineconcentrationssimilartolevels
foundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritation
Wefoundairendotoxinconcentrationsatlevelsthathave beenassociatedwithcoughandfever
WedidnotfindfecalcontaminationLegionella mycobacteriasulfitesorsulfatesinthepoolwater
WefoundthatwaterchemistryresultsmetOhiostate standards
Wefoundthatlifeguardshadmorework-relatedsymptoms thanemployeesnotworkinginsidetheindoorpoolarea
Wefoundthatlifeguardshadmorework-relatedcoughand eyeirritationondayswhenthenumberofpeopleusingthe indoorpoolareawashigh
Wefoundthattheventilationsystemdesignmaynotprovide adequateairmovementanddistribution
What Managers Can Do Managersshouldfurtherassesstheventilationsystem
toensureenoughairmovementandproperremovalof contaminants
Managersshouldconsiderreducingwaterattractioncycle timesandusinglargerdropletdischargenozzlestoreduce aerosolizationofcontaminants
Managersshouldconsiderredesigningthesprayfeature pipingsystemtomakesurethatwaterusedinthepoolsis takendirectlyafterthefiltrationandtreatmentcycle
Page v Health Hazard Evaluation Report 2007-0163-3062
HigHligHts of tHe Managersshouldmonitoranddocumentanysymptoms niosH HeAltH reportedbyemployeesandpatrons
HAzARd evAluAtion What Employees Can Do(Continued) Employeesshouldreportanysymptomsthatmaybework-
relatedtotheirsupervisors
Health Hazard Evaluation Report 2007-0163-3062 Page v
summARy
Lifeguards had significantly more work-related symptoms than employees who did not work in the indoor pool area they had more symptoms on days when hotel occupancy was high We found airborne chloramines and endotoxin which may have contributed to reported symptoms We recommend evaluating the ventilation system design to identify ways to increase air movement and reduce air contaminant levels at the pool deck level
InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedrespiratorysymptomseyeand noseirritationandskinrashes
InMarch2007wevisitedthesiteforthefirsttimeWemetwith managementWCCHDrepresentativesandanemployeelifeguard representativetouredthefacilityandinterviewedworkersina privatesetting
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredairtemperatureandRHandadministered questionnairestoemployeesregardingmedicaljobandpersonal historyandwork-relatedsymptomsWaterchemistrytestswere performedandwatersampleswerecollectedforLegionellafecal coliformbacteriamycobacteriaendotoxinsulfitesandsulfates Areviewwasconductedofthewatersystemandventilationsystem designs Thetrichloramineconcentrationswemeasuredweresimilarto thosefoundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritationAir endotoxinlevelsinallpoolareasexceptthewaterfortexceeded theACGIHproposedRLVforendotoxinexposure(10times thebackgroundlevelwhensymptomsconsistentwithendotoxin exposurearereported)WaterchemistryresultsmetOhiostate standardsNoLegionellamycobacteriaorfecalcoliformbacteria werefoundinanyofthewatersamplescollected
Lifeguardshadsignificantlymorework-relatedrespiratory symptomseyeandnoseirritationfeverbodyachesandskin rashesinthe4weekspriortoquestionnairecompletionthan employeeswhodidnotworkintheindoorpoolareaThe prevalenceofwork-relatedcoughandeyeirritationamongthe lifeguardswassignificantlyhigherondayswhenhoteloccupancy washigh
Ventilationdesignconcernsincludetheplacementofairsupply diffusersandreturnairinletsatheightsof30ndash80ftabovedeck levelThisheightmakesitdifficulttoprovideadequateair movementandmixingatthepoolsurfaceanddecklevelsand createsthepotentialforshortcircuitingofsupplyairtoexhaust
Page v Health Hazard Evaluation Report 2007-0163-3062
summARy(Continued) Thisreportcontainsrecommendationsfordecreasingthe
chloramineexposuresthoughttocausethereportedsymptoms includingmodificationandredesignoftheventilationsystemto increaseairmovementatthepooldecklevel
Keywords NAICS 713990 (All Other Amusement and Recreation Industries) chloramines trichloramine nitrogen trichloride indoor waterpark pools hot tubs spas sulfates sulfites endotoxin fecal coliform relative humidity Legionella mycobacteria cough respiratory symptoms rash eye irritation
Health Hazard Evaluation Report 2007-0163-3062 Page v
Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
HigHligHts of tHe
niosH HeAltH
HAzARd evAluAtion
The Warren County Combined Health District asked the National Institute for Occupational Safety and Health (NIOSH) to assist in investigating the cause of symptoms reported at the Great Wolf Lodge (GWL) indoor waterpark resort in Mason Ohio Symptoms included cough wheezing shortness of breath eye and nose irritation and skin rashes We conducted our investigation in March and April 2007
What NIOSH Did Wetestedtheairfortrichloraminesolublechlorine
compoundsandendotoxin
WetestedthewaterforfecalcontaminationLegionella mycobacteriaendotoxinsulfitesandsulfates
Wecheckedthewaterchemistryandreviewedthewater systemdesign
WeadministeredquestionnairestoGWLemployeesabout theirhealth
Wereviewedtheventilationsystemdesign
What NIOSH Found Wefoundtrichloramineconcentrationssimilartolevels
foundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritation
Wefoundairendotoxinconcentrationsatlevelsthathave beenassociatedwithcoughandfever
WedidnotfindfecalcontaminationLegionella mycobacteriasulfitesorsulfatesinthepoolwater
WefoundthatwaterchemistryresultsmetOhiostate standards
Wefoundthatlifeguardshadmorework-relatedsymptoms thanemployeesnotworkinginsidetheindoorpoolarea
Wefoundthatlifeguardshadmorework-relatedcoughand eyeirritationondayswhenthenumberofpeopleusingthe indoorpoolareawashigh
Wefoundthattheventilationsystemdesignmaynotprovide adequateairmovementanddistribution
What Managers Can Do Managersshouldfurtherassesstheventilationsystem
toensureenoughairmovementandproperremovalof contaminants
Managersshouldconsiderreducingwaterattractioncycle timesandusinglargerdropletdischargenozzlestoreduce aerosolizationofcontaminants
Managersshouldconsiderredesigningthesprayfeature pipingsystemtomakesurethatwaterusedinthepoolsis takendirectlyafterthefiltrationandtreatmentcycle
Page v Health Hazard Evaluation Report 2007-0163-3062
HigHligHts of tHe Managersshouldmonitoranddocumentanysymptoms niosH HeAltH reportedbyemployeesandpatrons
HAzARd evAluAtion What Employees Can Do(Continued) Employeesshouldreportanysymptomsthatmaybework-
relatedtotheirsupervisors
Health Hazard Evaluation Report 2007-0163-3062 Page v
summARy
Lifeguards had significantly more work-related symptoms than employees who did not work in the indoor pool area they had more symptoms on days when hotel occupancy was high We found airborne chloramines and endotoxin which may have contributed to reported symptoms We recommend evaluating the ventilation system design to identify ways to increase air movement and reduce air contaminant levels at the pool deck level
InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedrespiratorysymptomseyeand noseirritationandskinrashes
InMarch2007wevisitedthesiteforthefirsttimeWemetwith managementWCCHDrepresentativesandanemployeelifeguard representativetouredthefacilityandinterviewedworkersina privatesetting
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredairtemperatureandRHandadministered questionnairestoemployeesregardingmedicaljobandpersonal historyandwork-relatedsymptomsWaterchemistrytestswere performedandwatersampleswerecollectedforLegionellafecal coliformbacteriamycobacteriaendotoxinsulfitesandsulfates Areviewwasconductedofthewatersystemandventilationsystem designs Thetrichloramineconcentrationswemeasuredweresimilarto thosefoundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritationAir endotoxinlevelsinallpoolareasexceptthewaterfortexceeded theACGIHproposedRLVforendotoxinexposure(10times thebackgroundlevelwhensymptomsconsistentwithendotoxin exposurearereported)WaterchemistryresultsmetOhiostate standardsNoLegionellamycobacteriaorfecalcoliformbacteria werefoundinanyofthewatersamplescollected
Lifeguardshadsignificantlymorework-relatedrespiratory symptomseyeandnoseirritationfeverbodyachesandskin rashesinthe4weekspriortoquestionnairecompletionthan employeeswhodidnotworkintheindoorpoolareaThe prevalenceofwork-relatedcoughandeyeirritationamongthe lifeguardswassignificantlyhigherondayswhenhoteloccupancy washigh
Ventilationdesignconcernsincludetheplacementofairsupply diffusersandreturnairinletsatheightsof30ndash80ftabovedeck levelThisheightmakesitdifficulttoprovideadequateair movementandmixingatthepoolsurfaceanddecklevelsand createsthepotentialforshortcircuitingofsupplyairtoexhaust
Page v Health Hazard Evaluation Report 2007-0163-3062
summARy(Continued) Thisreportcontainsrecommendationsfordecreasingthe
chloramineexposuresthoughttocausethereportedsymptoms includingmodificationandredesignoftheventilationsystemto increaseairmovementatthepooldecklevel
Keywords NAICS 713990 (All Other Amusement and Recreation Industries) chloramines trichloramine nitrogen trichloride indoor waterpark pools hot tubs spas sulfates sulfites endotoxin fecal coliform relative humidity Legionella mycobacteria cough respiratory symptoms rash eye irritation
Health Hazard Evaluation Report 2007-0163-3062 Page v
Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
HigHligHts of tHe Managersshouldmonitoranddocumentanysymptoms niosH HeAltH reportedbyemployeesandpatrons
HAzARd evAluAtion What Employees Can Do(Continued) Employeesshouldreportanysymptomsthatmaybework-
relatedtotheirsupervisors
Health Hazard Evaluation Report 2007-0163-3062 Page v
summARy
Lifeguards had significantly more work-related symptoms than employees who did not work in the indoor pool area they had more symptoms on days when hotel occupancy was high We found airborne chloramines and endotoxin which may have contributed to reported symptoms We recommend evaluating the ventilation system design to identify ways to increase air movement and reduce air contaminant levels at the pool deck level
InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedrespiratorysymptomseyeand noseirritationandskinrashes
InMarch2007wevisitedthesiteforthefirsttimeWemetwith managementWCCHDrepresentativesandanemployeelifeguard representativetouredthefacilityandinterviewedworkersina privatesetting
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredairtemperatureandRHandadministered questionnairestoemployeesregardingmedicaljobandpersonal historyandwork-relatedsymptomsWaterchemistrytestswere performedandwatersampleswerecollectedforLegionellafecal coliformbacteriamycobacteriaendotoxinsulfitesandsulfates Areviewwasconductedofthewatersystemandventilationsystem designs Thetrichloramineconcentrationswemeasuredweresimilarto thosefoundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritationAir endotoxinlevelsinallpoolareasexceptthewaterfortexceeded theACGIHproposedRLVforendotoxinexposure(10times thebackgroundlevelwhensymptomsconsistentwithendotoxin exposurearereported)WaterchemistryresultsmetOhiostate standardsNoLegionellamycobacteriaorfecalcoliformbacteria werefoundinanyofthewatersamplescollected
Lifeguardshadsignificantlymorework-relatedrespiratory symptomseyeandnoseirritationfeverbodyachesandskin rashesinthe4weekspriortoquestionnairecompletionthan employeeswhodidnotworkintheindoorpoolareaThe prevalenceofwork-relatedcoughandeyeirritationamongthe lifeguardswassignificantlyhigherondayswhenhoteloccupancy washigh
Ventilationdesignconcernsincludetheplacementofairsupply diffusersandreturnairinletsatheightsof30ndash80ftabovedeck levelThisheightmakesitdifficulttoprovideadequateair movementandmixingatthepoolsurfaceanddecklevelsand createsthepotentialforshortcircuitingofsupplyairtoexhaust
Page v Health Hazard Evaluation Report 2007-0163-3062
summARy(Continued) Thisreportcontainsrecommendationsfordecreasingthe
chloramineexposuresthoughttocausethereportedsymptoms includingmodificationandredesignoftheventilationsystemto increaseairmovementatthepooldecklevel
Keywords NAICS 713990 (All Other Amusement and Recreation Industries) chloramines trichloramine nitrogen trichloride indoor waterpark pools hot tubs spas sulfates sulfites endotoxin fecal coliform relative humidity Legionella mycobacteria cough respiratory symptoms rash eye irritation
Health Hazard Evaluation Report 2007-0163-3062 Page v
Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
summARy
Lifeguards had significantly more work-related symptoms than employees who did not work in the indoor pool area they had more symptoms on days when hotel occupancy was high We found airborne chloramines and endotoxin which may have contributed to reported symptoms We recommend evaluating the ventilation system design to identify ways to increase air movement and reduce air contaminant levels at the pool deck level
InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedrespiratorysymptomseyeand noseirritationandskinrashes
InMarch2007wevisitedthesiteforthefirsttimeWemetwith managementWCCHDrepresentativesandanemployeelifeguard representativetouredthefacilityandinterviewedworkersina privatesetting
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredairtemperatureandRHandadministered questionnairestoemployeesregardingmedicaljobandpersonal historyandwork-relatedsymptomsWaterchemistrytestswere performedandwatersampleswerecollectedforLegionellafecal coliformbacteriamycobacteriaendotoxinsulfitesandsulfates Areviewwasconductedofthewatersystemandventilationsystem designs Thetrichloramineconcentrationswemeasuredweresimilarto thosefoundinotherindoorswimmingpoolstudiesandsome wereatlevelsreportedtocausemucousmembraneirritationAir endotoxinlevelsinallpoolareasexceptthewaterfortexceeded theACGIHproposedRLVforendotoxinexposure(10times thebackgroundlevelwhensymptomsconsistentwithendotoxin exposurearereported)WaterchemistryresultsmetOhiostate standardsNoLegionellamycobacteriaorfecalcoliformbacteria werefoundinanyofthewatersamplescollected
Lifeguardshadsignificantlymorework-relatedrespiratory symptomseyeandnoseirritationfeverbodyachesandskin rashesinthe4weekspriortoquestionnairecompletionthan employeeswhodidnotworkintheindoorpoolareaThe prevalenceofwork-relatedcoughandeyeirritationamongthe lifeguardswassignificantlyhigherondayswhenhoteloccupancy washigh
Ventilationdesignconcernsincludetheplacementofairsupply diffusersandreturnairinletsatheightsof30ndash80ftabovedeck levelThisheightmakesitdifficulttoprovideadequateair movementandmixingatthepoolsurfaceanddecklevelsand createsthepotentialforshortcircuitingofsupplyairtoexhaust
Page v Health Hazard Evaluation Report 2007-0163-3062
summARy(Continued) Thisreportcontainsrecommendationsfordecreasingthe
chloramineexposuresthoughttocausethereportedsymptoms includingmodificationandredesignoftheventilationsystemto increaseairmovementatthepooldecklevel
Keywords NAICS 713990 (All Other Amusement and Recreation Industries) chloramines trichloramine nitrogen trichloride indoor waterpark pools hot tubs spas sulfates sulfites endotoxin fecal coliform relative humidity Legionella mycobacteria cough respiratory symptoms rash eye irritation
Health Hazard Evaluation Report 2007-0163-3062 Page v
Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
summARy(Continued) Thisreportcontainsrecommendationsfordecreasingthe
chloramineexposuresthoughttocausethereportedsymptoms includingmodificationandredesignoftheventilationsystemto increaseairmovementatthepooldecklevel
Keywords NAICS 713990 (All Other Amusement and Recreation Industries) chloramines trichloramine nitrogen trichloride indoor waterpark pools hot tubs spas sulfates sulfites endotoxin fecal coliform relative humidity Legionella mycobacteria cough respiratory symptoms rash eye irritation
Health Hazard Evaluation Report 2007-0163-3062 Page v
Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Thispageintentionallyleftblank
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
intRoduCtion InMarch2007NIOSHreceivedatechnicalassistancerequest fromtheWCCHDtoinvestigatethecauseofsymptomsreported byemployeesattheGWLindoorwaterparkresortinMason OhioReportedsymptomsincludedcoughwheezingshortness ofbreathchesttightnesssorethroateyeandnoseirritationand skinrashes
TheWCCHDbeganreceivinghealthcomplaintsfromGWL patronsinJanuary2007GWLmanagementrespondedby inspectingtheventilationsystemwaterfiltrationsystemand waterchemistryWaterchemistrytestswerealsoperformed bytheWCCHDandresultscompliedwithstatecodes[Ohio DepartmentofHealth2003]GWLhiredaconsultanttotake chlorineairsamplesonJanuary312007Theninechlorineair samplesweretakenover15minutesatvariouslocationsinthe poolareaandhadconcentrationsbelowtheNIOSHRELof05 ppmandtheOSHAPELof1ppmChlorinelevelswerehighest aroundtheleisureriverattractionat04ppmEventhoughthis levelwasbelowboththeNIOSHRELandOSHAPELGWL addedtwosupplydiffuserstotheairductsabovethisareaand onesupplydiffuserabovethehottubareaonMarch92007 GWLalsoincreasedwaterchemistrychecksfromevery4hours toevery2hoursreducedwaterchlorineconcentrationstothe lowestconcentrationpossiblewhilestillmaintainingitabovethe minimumstate-requiredlevelreducedpHloweredairtemperature andhumiditylevelsandaddedmorefreshwatertoallsystems HoweverWCCHDcontinuedtoreceivehealthcomplaintsfrom patronspromptingatechnicalassistancerequesttoNIOSH
InMarch2007wevisitedthesiteforthefirsttimeDuringthe sitevisitwemetwithmanagementWCCHDrepresentatives andanemployeelifeguardrepresentativetouredtheindoor waterparkandprivatelyinterviewedseverallifeguardsabouttheir medicalstatusMostoftheinterviewedlifeguardsreportedeyeand respiratoryirritationatworkTheyalsoreportedrecurrentcough withfeverLifeguardsreportedthattheirsymptomswereworse whenthebatherload(numberofpeopleusingtheindoorpool area)washighandwhenoutdoorairtemperatureswerecolder Basedonthosemedicalinterviewswedeterminedthatfurther investigationwaswarranted
InMarchandApril2007wecollectedareaairsamplesfor trichloraminesolublechlorinecompoundsandendotoxin WealsomeasuredtemperatureandRHandadministered
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
intRoduCtion (Continued) questionnairestoemployeesregardingmedicaljobandpersonal
historyaswellaswork-relatedsymptomsWaterchemistrytests wereperformedandwatersampleswerecollectedforLegionella fecalcoliformbacteriamycobacteriaendotoxinsulfitesand sulfatesAreviewwasconductedofthewatersystemandair distributionsystemdesignsAninterimletterwasprovidedon April92007withthepreliminaryresultsoftheairsampling performedonMarch202007
Process Description
GWLisanindoorwaterparkresortchainwith10locations acrosstheUnitedStatesTheMasonOhiofacilityopened onDecember142006andincludesroomsuitesanindoor waterparkconferencecenterfitnesscenterrestaurantsshops andanarcadeTheOhioDepartmentofAgriculturersquosDivision ofAmusementRideSafetymaintainsjurisdictionoverthe aquaticamusementridesandassociatedpoolsandtheWCCHD maintainsjurisdictionoverthetwohottubsTheapproximately 80000-ft2waterparkhas11waterslidestwoactivitypoolstwo hottubsawavepoolaleisureriverafour-storyinteractiveplay systemandavarietyofwaterfeaturesthatsplashsprayandaerate largeamountsofwaterThetotalwatervolumeattheGWLisover 400000gallonsthetotalwatersurfaceareaisover15000ft2and thedepthrangesfrom0to5ftThemaximumoccupancyforthe waterparkis3746[OhioFireCode2006]andguestscanvisitthe poolareafrom9amto10pm
GWLemploysabout500employeesattheMasonfacilityOfthe approximately100lifeguards50ndash60areunder18yearsofage Duetoemployeeturnoverthenumberoflifeguardsfluctuates butapproximately30workfull-timeand70workpart-time Lifeguardsworkmainlytwoshifts830amto430pmand400 pmto1100pmwithafewworkingthe1100amto800pm breakshiftLifeguardspatroladefinedsectionofthewaterpark androtatethroughdifferentlocationsevery30minutes
Water Systems
TheGWLhassevenmajorwatersystemsthatcirculatedisinfect andfilterwater24hoursadayEachwatersystemisself-contained withindividualmonitoringandregulatingcomponentsWater flowsbygravitythroughthemaindrainsandguttersystemsfrom
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
intRoduCtion (Continued) thepoolintodesignatedsurgetanksWaterforthesprayfeaturesis
drawndirectlyfromthesurgetanksHowevermostofthewateris pumpedoutofthesurgetankintothefiltrationsystemThefilter containssyntheticdiatomaceousearthfiltermediawhichremoves particlesdownto10micron[Zajo2008a]Filterbedsareagitated nightlytoredistributethefiltermediaandaccumulateddebrisinto auniformfilteringsurfaceFiltermediaisreplacedapproximately every3weeksThefilterinfluentandeffluentpressureischecked dailytomonitorthefiltrationefficiency
ThefilteredwaterthenpassesthroughaUVunitwhichoperates ataminimumof60mjcm2tobreakdowncombinedchlorineand providesecondarydisinfectionNaturallyoccurringlevelsofiron ormanganeseintheincomingpublicwatersupplymaydeposit asaresidueontheUVquartzsleevesWhenenoughresidue accumulatessothatthelightemittedthroughthequartzsleeve fallsbelow60mjcm2areal-timemonitoringsensorintheUV unitshowsalowdosereadingAdditionallytechnicianscheckthe sensorreadingsevery2hoursIfalowdosereadingisobserved thefouledsleevesarecleanedwithadiluteacidsolutiontoremove theresidue
Thewaterthenpassesthroughanautomatedchemicalcontroller systemthatmonitorsandmaintainswaterpHandfreechlorineAs neededthecontrollerinjectssulfuricacidsolution(toadjustthe pHofthewater)andsodiumhypochloritesolution(todisinfect thewater)intotherecirculationpipeAfterthewaterchemistryis adjustedthewaterisheatedtomaintainpooltemperatureThe wateristhensentbacktothepoolthroughfloordiffusers
Inadditiontotheautomatedchemicalcontrollersystem techniciansmanuallycheckwaterchemistryparametersincluding pHalkalinityfreechlorineandcombinedchlorineTechnicians takewatersamplesfromvalvesinstalledineachofthesystems neartheautomatedchemicalcontrollersandtestwaterchemistry TheresultsarerecordedinalogbookWatersamplesarealso collectedpoolsideatelbow-lengthdepthduringparkopeningand closingtimesandarecomparedwiththeautomatedchemical controllerreadingsGWLaimstomaintainpHbetween72and 74combinedchlorinelessthan02ppmandfreechlorine concentrationsbetween12and16ppmGWLrsquostargetrangefor totalchlorineis15to20ppmforpoolsand25to30ppmfor thehottubs
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
intRoduCtion (Continued) Waterlevelsarecheckedvisuallyevery2hoursbytechnicians
andcontinuouslybyautomatedautofilldevicesAnautofill devicemonitorsthewaterlevelbyusingfloatsinthesurge tanksandaddsfreshwaterwhenthewaterlevelfallsbelowa predeterminedsetpointGWLreplacesallwaterfromthefamily andadulthottubsatleastonceaweekTechniciansalsoperform acompletewaterchangeofthehottubsifthecombinedchlorine concentrationsriseabovesetlevels
ThewaterforGWLrsquoswaterfeaturescomesfromseparatewell fieldsonelocatedontheeastsideoftheLittleMiamiRiver BuriedValleyAquiferandtheotheratShakerCreekBuried ValleyAquiferIronandmanganeseareremovedbyaerationand filtrationfluorideandchlorineareaddedThesupplywaterisnot chloraminated
Ventilation System
Eightairhandlingunitsprovideheatingandventilationtothe GWLindoorwaterparkareaEachunitisdesignedtoprovide anairsupplyflowrateof18830cfmtothewaterparkthrougha 48-inchdiametermainductTheactualflowratehowevermay differdependingonthesystemdesignandinstallationTheunits operateindifferentmodesdependingonoutsideenvironmental conditionsandcontrolsetpointsTheunitsalsorecoverheatfrom theexhaustairThecontrolsetpointsforeachairhandlingunit are86ordmFairtemperatureand83ordmFwatertemperature[Zajo2008a] TheRHsetpointrangeis55ndash65Feedbackfromtemperature andhumiditysensorsinthereturnairductsofeachindividual airhandlingunitisusedtomaintaintheoveralltemperatureand humiditywithinthecontrolsetpoints
Whentheoutdoorairtemperatureisabove40ordmFtheairhandling unitsprovide100outdoorairwithnoairrecirculation[Neuman 2007]Below40ordmFtheairhandlingunitsrecirculateanincreasing amountofairtoamaximumof33(minimum67outdoor airsupply)basedontheoutdoorairtemperatureTworeturn airintakesarelocatedatdeckheightalongthenorthwallofthe waterparknearthefamilyhottubpoolandthewavepoolEach oftheseintakesreturnsapproximately19000cfmtotheair handlingunitsAnadditionalfourreturnairintakesarelocated approximately60ndash80ftabovethepooldeckonthenorthwallof themiddlehighbayareaofthewaterparkThesefourhighbay returnairductsare48inchesindiameterandreturnapproximately
Page Health Hazard Evaluation Report 2007-0163-3062
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
intRoduCtion (Continued) 38000cfmeachAccordingtodesigndrawings70ofthereturn
airispulledfromthehighbayareaandapproximately30is pulledfromthelowerreturnairintakes
Theairhandlingunitshavethecapabilitytorecirculate100of thewaterparkairwhileintheldquounoccupiedmoderdquoThismodecan besetbasedonatimerorconditionsinthefacilityTheunitsare programmedtogointotheunoccupiedmodeonehalfhourafter thefacilityclosesuntil2hoursbeforethefacilityopensHowever theunitsmayremainintheldquooccupiedmoderdquoduringthesetimesif thehumidityinthefacilityisgreaterthan40RH
Airissuppliedtothewaterparkthroughaseriesof48-inch diameterductsthatrunalongtheceilingTheairsupplyductsare equippedwithdrum-typediffuserstypically10x30inchesinsize withasupplyflowrateofapproximately1800cfmeachInsome locationsalongthemainductsmallerdiffuserswithlowersupply airflowratesareusedThemainductdiameterisreducedinsizeas itextendsfurtherfromtheairhandlingunittoprovidebalancing ofairflowthroughtheoutermostairsupplydiffusersTheair supplydiffusersarelocatedapproximatelybetween30ndash80ftabove deckleveldependingonthelocationandthereturnairducts arelocatedbetween60ndash80ftabovedecklevelThefourmajorair supplyductsservice(1)leisureriverandwaterslide(2)leisure riverwavepoolandsouthconcessionarea(3)activitypoolsand playstructureand(4)childrenrsquosactivitypoolandhottubsTwo airhandlingunitssupplyeachoftheseductsdeliveringanominal flowrateofapproximately38000cfm
Association of Chloramines and Symptoms in Indoor Pool Environments
Numerouscasereportsofeyeandupperrespiratorytractirritation amongbathersandemployeeshavebeenreportedatchlorinated indoorswimmingpoolsAlthoughmanyDBPscanbeproduced bythemixtureofdisinfectantsandcompoundsfoundinpool waterchloraminesspecificallytrichloraminearesuspectedasa primarycauseofreportedirritationsymptomsbasedonexposure monitoringstudies[Heryetal1995Massinetal1998] ChloraminesareDBPsthatformwhenchlorinecombineswith nitrogen-containingcompoundssuchassweatandurineThey includetheinorganiccompoundsmonochloraminedichloramine andtrichloramineIncreasedbatherloadhasbeensignificantly
Health Hazard Evaluation Report 2007-0163-3062 Page
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
intRoduCtion (Continued) associatedwithanincreaseintrichloraminelevels[Jacobset
al2007]Thisismostlikelyduetotheincreaseintheamount ofnitrogencompoundsproducedsweatcontainsabout1gL ofnitrogen[WHO2006]andtheaverageamountofurine releasedintopoolwatersperbatheris25to30mL[Gunkeland Jessen1988]Behaviormodificationssuchasshoweringbefore enteringandleavingthepoolareaandtakingbathroombreaks candecreasetheamountofnitrogenouswastecontaminating poolwater[Dziubanetal2006]Otherfactorsaffectingthe chloramineconcentrationinindoorpoolenvironmentsinclude waterchemistryparameters(egchlorineconcentrationpH temperature)aerosolizationofparticlescausedbysplashingand sprayingandairrecirculation[Heryetal1995Massinetal 1998]
Trichloramineismorevolatilethanmonochloramineand dichloramineandisthemainchloraminecompoundpresent abovechlorinatedwatersurfaces[Holzwarthetal1984]Itisa strongmucousmembraneirritant[Barbee1983]andhasbeen associatedwitheyeandupperrespiratorytractirritationin swimmersandpoolattendants[Massinetal1998]Trichloramine poseslessofahealthconcerninoutdoorswimmingpoolsbecause itdissipatesintotheearthrsquosatmosphereHoweverenclosedindoor swimmingpoolscombinedwithinadequateventilationandpoor waterchemistrycontrolcancauseairborneDBPstoaccumulate
ResearchersattheINRSinFrancedevelopedasamplingand analyticmethodformeasuringchloraminesintheair[Heryetal 1998]NIOSHinvestigatorshavedevelopedadraftmethodthatis amodificationoftheINRSmethodAdetaileddescriptionofthe NIOSHsamplingandanalyticalmethodcanbefoundinAppendix BThesesamplingandanalyticmethodshavebeenusedina varietyofworkplacesincludingindoorswimmingpoolspoultry facilitiesandagreensaladprocessingplantwherechloramine exposurehasbeenlinkedtoeyeandupperrespiratoryirritation [Heryetal1995Heryetal1998NIOSH2003NIOSH2006]
AdditionalinformationonOELsandhealtheffectsofchloramines canbefoundinAppendixC
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
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Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Assessment Water
OnMarch202007representativesfromWCCHDNIOSH andNCEHtouredtheaquaticfacilityincludingchemicalstorage disinfectionmonitoringandinjectionrecirculationandfiltration systemsandthesevenaquaticfeaturesPoolwaterwastestedfor pHfreeandtotalchlorineandalkalinityTheNCEHinvestigator reviewedtheconstructionplanstoassesswatersystemdesign includingwaterrecirculationfiltrationanddisinfectionprocesses
OnMarch282007environmentalhealthstafffromtheWCCHD andtheOhioDepartmentofHealthcompletedtheCDC EnvironmentalHealthOutbreakInvestigationSurveytoassistthe overallinvestigationThisenvironmentalhealthsystemassessment includedacomprehensivereviewoftheaquaticfacilityincludinga descriptionofthewatersystemswaterflowandtreatmentdesign andhygienepoliciesandpractices
Ventilation
Weinterviewedmaintenancemanagersandtheventilation designcontractortoobtaininformationontheoperationand maintenanceoftheairdistributionsystemsAvisualinspection wasmadeoftheventilationsystemservingthepoolareaincluding theairhandlingunitsandheightandlocationofsupplyand returndiffusersParameterssuchaspoolanddeckareaoverallair supplyflowrateandairchangeratesweredeterminedusingcopies ofmechanicalplansblueprintsandairhandlingunitdrawings providedbyGWLandtheirventilationcontractorNominal designairsupplyflowratesprovidedontheairhandlingunit drawingswerecomparedtothosemeasuredbyanindependenttest andbalancetechniciancertifiedbytheNationalEnvironmental BalancingBureauin2007Thetotalsquarefootageandvolume oftheindoorwaterparkareawerecalculatedandusedtocompute outsideventilationratesperpoolanddeckareaforcomparison withbuildingcodeandconsensusstandardsWealsocontacted theMasonbuildinginspectortodiscusstheOhioBuildingCode andinspectionprocess
Industrial Hygiene
Wehavehighlightedthesamplingmethodologyinthesections belowAdditionaldetailsonsamplingandanalyticalmethodscan befoundinAppendixB
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Assessment (Continued) Chloramine Measurements
Trichloramineandsolublechlorinecompounds(monochloramine dichloraminehypochlorousacidandhypochlorite)werecollected usingthesamesamplingtrainthereforeunlessspecifiedtheterm chloraminesreferstobothtrichloramineandsolublechlorine compounds
Toassesstheeffectofbatherloadonairchloraminelevelswe collectedareaairsamplesforchloraminesonhighandlowbather loaddays(asapproximatedbyhoteloccupancy)March20(1153 guestsbooked)andApril14(1308guestsbooked)wereselectedas highbatherloaddaysandApril24wasselectedasalowbather loadday(70guestsbooked)NoPBZsamplesweretakenbecause PBZsamplingequipmentattachedtothelifeguardscouldinterfere withtheirrescuedutiesandgetwetChloraminesampleswere takenateightlocationsapproximately3ndash4ftabovethedeckinthe poolareaoftheindoorwaterparkandacontrolsamplewastaken inanadministrativeofficeoutsidethepoolareaAnadditional sampleatthewaterfortlocationwastakenonApril14only
OnMarch202007trichloramineconcentrationswere measuredoverone8-hourshiftin4-hourincrementsandthe solublechlorineconcentrationsweremeasuredin2-and4-hour incrementsThesolublechlorineconcentrationsweremeasured overvaryingtimeperiodstoassesswhetherthehumidityinthe poolareawouldsaturatethesamplingmediaOnApril14and April24bothtrichloramineandsolublechlorinesampleswere takenovertwoconsecutive8-hourshiftsin4-hourincrementsand overa2-hourincrementbeforethepoolopenedandafteritclosed
TemperatureandRHweremonitoredalongsideeachchloramine samplinglocationDatawasrecordedeveryminuteusingaHoboreg H8ProSeriesdata-logger(OnsetComputerCorporationPocasset Massachusetts)andspotmeasurementsweretakenwithaQshyTrakTMPlusmonitor(TSIModel8554ShoreviewMinnesota)
Endotoxin Measurements
Areaairandbulkwaterendotoxinconcentrationsweremeasured becauseoflifeguardreportsofrecurringfeverbodyachesand chest-flu(feverandcoughorpneumonia)symptomsBulkwater samplesforendotoxinweretakenpoolsidefromeachwater
Page Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Assessment (Continued) filtrationsystemandtwoofthesurgetanks(childrenrsquospooland
leisureriver)onApril142007Controlsamplesweretaken fromtherestroomtapwaterAreaairsamplesforendotoxin concentrationswerecollectedthroughoutthewaterparkanda controlsamplewastakeninanadministrativeoffice
Microbial Measurements
BulkwatersamplesforLegionellaandmycobacteriawereobtained toidentifyotherpossiblecausesofrespiratorysymptomsBulk watersamplesweretakenatninelocationswithatleastone samplecollectedpoolsidefromeachwaterfiltrationsystemandtwo ofthesurgetanks(childrenrsquospoolandleisureriver)onMarch28 2007Watersamplesweretakenforfecalcoliformbacteriaatthe samelocationsonApril242007tocheckforfecalcontamination
Sulfate and Sulfite Measurements
Bulkwatersamplesweretakenpoolsideforsulfatesandsulfites fromeachfiltrationsystemonMarch282007Thesewater samplesweretakenattherequestofGWLmanagementbecause ofcertainpatronsrsquobeliefsthattheirskinrashresultedfroma preexistingldquosulfurallergyrdquo
Medical Interviews
DuringtheinitialsitevisitNIOSHphysiciansconducted confidentialmedicalinterviewswith10lifeguardsfromtheday shiftManagementselectedeightlifeguardsandNIOSHselected twoInterviewquestionsconcernedpersonalcharacteristics medicalhistoryjobdutiesandwork-relatedsymptoms
Symptom Questionnaires
BetweenMarch20andApril24exposedindividuals(lifeguards workinginsidethepoolarea)andunexposedindividuals (employeesnotworkinginsidethepoolarea)filledoutaninitial questionnaireconcerningdemographicsworkplaceinformation smokingstatusmedicalhistoryepisodesofpneumoniaorchest fluwithfeverandcoughsinceworkingatGWLandwork-related
Health Hazard Evaluation Report 2007-0163-3062 Page
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Assessment (Continued) symptomswithintheprior4weeksUnexposedindividualsworked
inGuestServicesArcadeBearClawCafeacuteBuckhornRetailand StarbucksAllparticipationwasvoluntaryweobtainedwritten informedconsentfromtheparentsofallstudyparticipantsunder theageof18years
Lifeguardscompletedanadditionalquestionnaireatthe endoftheirworkshiftondaysthatchloramineairsampling wasconductedItcontainedquestionsrelatingtosymptoms experiencedduringtheirworkshiftthatday
Healthoutcomesofinterestincludedwork-relatedrespiratory symptoms(coughwheezingshortnessofbreathchesttightness) mucousmembraneirritation(coughsorethroateyeandnose irritation)systemicsymptoms(feverbodyaches)andskin rashesParticipantswereaskednottoreportsymptomsassociated withacoldorrespiratoryinfectionSymptomswereconsidered work-relatediftheyoccurredonthedaysoreveningsthatthe employeeworkedandimprovedondaysoffworkQuestions aboutrecurrentepisodesofpneumoniaorchestfluwithfeverand coughexperiencedatGWLwereusedtoidentifypotentialcasesof hypersensitivitypneumonitis
Statistical Analysis
StatisticalanalysiswascarriedoutwithSASversion913software (SASInstituteCaryNC)One-wayanalysisofvariancewasused tocomparethehumidityandtemperaturearithmeticmeansfor variouslocationsinthepoolareaAP value le 005 was considered statisticallysignificantAveragechloramineconcentrationswere calculatedacrosslocationusingtime-weightedmeansTocalculate time-weightedmeanssamplingresultsthatwerebelowtheLOD wereassignedavaluebydividingtheLODbythesquarerootof twoValuesbetweentheLODandLOQwerecalculatedfromthe laboratoryrsquosbestestimate
Prevalenceratioswith95confidenceintervalswerecalculatedto comparework-relatedsymptomsinthelast4weeksfortheexposed andunexposedemployeesAprevalenceratiowasconsidered statisticallysignificantifthe95confidenceintervalexcluded thenumberoneGeneralizedlinearmodelswereusedtocompare respiratorysymptomsfortheexposuregroupswhilecontrolling forsmokingstatus(currentsmokerornot)andasthmastatus
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Assessment (Continued) Anemployeewasdefinedashavingasthmaifheorshehadit
currentlyitwasdiagnosedbyahealthprofessionalanditbegan beforestartingworkatGWL
Wealsocalculatedprevalenceratiostocomparework-related symptomsforlifeguardsondaysofhighandlowhoteloccupancy Generalizedestimatingequationswereusedtoaccountforpossible correlationsbetweenresponseswhenalifeguardfilledoutthe additionalquestionnaireonmorethanonedayTheanalyses involvingrespiratorysymptomswereadjustedforsmokingstatus Employeeswithasthmawereexcludedfromtheseanalyses
Results Water
WaterchemistryresultsareoutlinedinTableA1inAppendixA ParametersincludedwaterpHandfreeandcombinedchlorine concentrationsMultiplemeasurementsineachsystemweretaken toidentifypotentialareasofinadequatewatercirculationThis canbeindicatedbydifferencesinwaterchemistryreadingstaken fromthesamewatersystemMostwatersystemshadconsistent measurementshoweverdifferenceswerenotedinsomewater systemsAtthechildrenrsquospoolwatercollectedatthegeyserspray featurehadapHof78whereaswatercollectedonthewestpool edgehadapHof70Inthechildrenrsquospoolwatersystemthe geysersourcewaterisdrawnfromthefeaturersquossurgetankwhich bypassesthetreatmentsystem
Theenvironmentalhealthsystemassessmentshowedthatthe facilitydesignandindividualaquaticfeaturesmetorexceededthe statersquosstandardsWiththeexceptionoftwolowpHreadings(70 and71)onMarch20disinfectionparameterswereacceptable TheselowpHreadingswerenotsignificantwhenaveragedwith otheracceptablereadingstakenfromthesamewatersystem ThewaterchemistrytestsperformedonMarch20andduring theenvironmentalhealthassessmentonMarch28metstateand localstandards[OhioDepartmentofHealth2003]Thefree andcombinedchlorineconcentrationsrecordedintheGWL recordkeepinglogsonthedaysofsamplingarelistedinTableA2 inAppendixA
Health Hazard Evaluation Report 2007-0163-3062 Page
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Results Ventilation (Continued) BasedontheGWLblueprintstheindoorwaterparkareais approximately80000ft2andapproximately4millionft3intotal volumeUsingthesquarefootagevolumeandtheairsupply volumetricflowratestakenfromthetestandbalancereportthe calculatedmaximumairexchangerate(withoutrecirculation) isapproximately20ACHandtheminimumairchangerate isapproximately13ACH(with33ofairrecirculated)The minimumoutdoorairflowrateisapproximately88000cfmbased ontheresultsfromthetestandbalancereportandthemaximum recirculationconditionof33duringoccupiedoperations
Industrial Hygiene
Chloramines
Two-hundredandfiveareaairsamplesweretakeninsidetheGWL poolareaSummariesofmeasurementscollectedonhighhotel occupancydays1and2(March20andApril14respectively) andthelowhoteloccupancyday(April24)areshowninTables 1and2withmoredetailedresultsinTablesA3A4andA5in AppendixATables1and2alsoindicatethepercentageofsamples thatfellbelowtheLOD(non-detectable)betweentheLODand LOQ(trace)andabovetheLOQ(quantifiable)
Table 1 Trichloramine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
16 45 38
ND ndash 066 ND ndash 106 ND ndash Trace
20 9
30
56 170 230
6 18 97
0 62 3
94 20 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ
Table 2 Soluble Chlorine Air Concentrations Samples of Range LOD LOQ Samples Samples Hotel Occupancy between Samples (mgm3) (microgsample) below LOD above LOQ LOD LOQ
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy
22a
45 39
ND ndash Trace 009 ndash 025 ND ndash ND
70 5
20
250 16
150
94 0
100
6 20 0
0 80 0
ND = Non detectable (below the LOD) Trace = Values between the LOD and LOQ a In some locations two 2-hour soluble chlorine samples were collected for every 4-hour trichloramine sample
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
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Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Results (Continued) TheLODandLOQvaluesvariedgreatlyoneachsamplingday
TheLODisthelevelatwhichthecompoundofinterestcanbe detectedanddistinguishedfromtheblankresponseTheLOD isdeterminedbythevariabilityoftheresponsesofblanksand lowlevelstandardsTheLOQistheminimumlevelthatcan bereportedwithconfidenceTheLOQisdeterminedeitheras 333timestheLODorthelevelatwhichtheminimumrecovery formediaspikesis75whicheverishigherTracevaluesor valuesbetweentheLODandLOQindicatesampleswherethe compoundwasdetectedhoweverlevelsweresolowthatthey couldnotbequantifiedreliably
Onhighoccupancyday138chloraminesamplesweretaken (16trichloramineand22solublechlorinesamples)Onthisday themajority(94)oftrichloraminesampleswasquantifiable andthecalculatedmeanwas044mgm3Meanconcentrations werecalculatedateachsamplinglocationThehighestmean trichloramineconcentrationbylocation(057mgm3)andthe overallhighesttrichloramineconcentrationcollected(066mgm3) wereattheleisureriverattractionwhichcontainswaterslides sprayfeaturesandsplashpoolsThemajority(94)ofsoluble chlorineconcentrationssampledonthisdayfellbelowtheLOD Thereforewedidnotcalculateameanvalueforsolublechlorine compoundsonthisdaySeeTablesA3ndashA5inAppendixAfor completechloramineresults
Onhighoccupancyday290chloraminesamplesweretaken(45 trichloramineand45solublechlorinesamples)Oftrichloramine samplescollectedonthisday82haddetectableconcentrations howeveronly20ofallsampleswerequantifiableAlthoughthis datahadmanynon-quantifiableconcentrationsitalsocontained thehighesttrichloramineconcentrationfound(106mgm3)of allsamplescollectedThishighconcentrationwasobtainedatthe leisureriverwhichalsohadthehighestmeanconcentrationby location(080mgm3)Themajority(80)ofsolublechlorine concentrationsonthisdaywasquantifiablewithamaximum concentrationof025mgm3andameansolublechlorine concentrationof017mgm3Nomajordifferenceswereobserved acrosslocationsforsolublechlorine
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Results (Continued) Onthelowoccupancyday77chloraminesampleswerecollected
(38trichloramineand39solublechlorinesamples)Allofthe solublechlorinesamplescontainednon-detectableconcentrations Onlyonetrichloraminesamplecontainedadetectable concentrationwhichwasreportedatatracelevelTherefore meansfortrichloramineandsolublechlorinesampleswerenot calculated
Endotoxin
AirandwaterendotoxinlevelsareshowninTablesA6andA7in AppendixAAirendotoxinconcentrationsinthepoolarearanged from18to84EUm3withameanconcentrationof45EUm3 Theseairendotoxinlevelswereabout10to40timeshigherthan levelstakeninanadministrativeofficeoutsidethepoolarea Thelocationswiththehighestairconcentrationswerethewave pool(84EUm3)andleisureriver(67EUm3)Thehighestwater endotoxinconcentrationswerealsofoundinthewavepool(61 EUmL)andleisureriver(77EUmL)Endotoxinlevelswere similarinthewatersystemswheresamplesweretakenfromboth thesurgetanksandsurfacewaterEndotoxinconcentrationsin watersamplestakenfromthehottubswereverylowandinsome casesmeasuredlowerthanthosefoundintapwaterwhichwe sampledforcomparison
Air Temperature and Relative Humidity
AverageairtemperatureandRHresultsareshowninTableA8 inAppendixAAirtemperatureaveragestakenacrosslocations rangedbetween82ordmFand89ordmFwiththehighesttemperatures locatedatthetopoftheslidetowerRHaveragesacrosslocations rangedfrom43to69withhighobservationsnotedatthe towelrackandneartheleisureriverRHandtemperaturetaken atdecklevel(excludesmeasurementstakenatthetopoftower) differedsignificantlyacrosslocations(Plt001)Theaverage RHvariedbyabout37acrosslocationsatdecklevelonhigh occupancyday1anditdifferedbyover30acrosslocationsat decklevelonhighoccupancyday2andthelowoccupancyday
Microbials
NoLegionellafecalcoliformbacteriaormycobacteriawerefound inanyofthewatersamples
Page Health Hazard Evaluation Report 2007-0163-3062
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Results Sulfates and Sulfites(Continued) Sulfateconcentrationsinwatersamplesrangedfrom940mgLto 1600mgLNosulfitesweredetectedTheLODforsulfitewas05 mgL
Medical Interviews
The10interviewedlifeguardsallreportedacoughthatthey associatedwithworkandthatimprovedondaysoffworkThree employeeshadasthmabeforeworkingatGWLandonereported thatasthmasymptomshadworsenedsinceworkingatGWLTwo employeesreportedincidentsofvomitingcausedbyexcessive coughingsevenreportedeyeirritationthreereportednose irritationthreereportedskinrashandoneemployeereportedtwo episodesofflu-likesymptomswithcoughandfeverOneemployee reportedintermittentblurryandhalovisioninoneeyeWhenthe visualsymptomsoccurredtheyalwaysstartedafterthebeginning oftheshiftandtypicallyresolvedwithinacouplehoursofleaving workTheemployeeusedonecontactlensanddidnotexperience blurryvisionintheeyewiththelensIngeneralemployees reportedthattheirsymptomswereworsewhenthebatherloadwas highandwhentheoutsidetemperaturewascolder
Initial Questionnaire
Seventyof103exposedlifeguards(68)and74of99(75) employeesworkingoutsidetheindoorpoolareacompletedthe initialquestionnairewithinthetimeperiodMarch202007 ndashApril22007Dataanalysiswasrestrictedtoquestionnaires receivedMarch202007ndashApril22007becausethistimeperiod wascolderandmorerepresentativeoftheoutdoortemperature wheninitialsymptomswerereportedThisdaterestriction excludeddatafrom12exposedindividuals
DemographiccharacteristicsaresummarizedinTable3Exposed individualswereyoungerthanunexposedindividualsTheywere similarintermsofmeanworkhoursperweekpersonalhistoryof asthmadiagnosedbyadoctororotherhealthprofessionalpriorto employmentatGWLandpersonalhistoryofhayfeverorother non-drugallergies
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
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RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
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RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Results (Continued)
Table 3 Demographic Characteristics
Characteristic Exposed (N = 69 ndash 70)
Unexposed (N = 74)
Age ndash average (range) 20 (16 ndash 50) 31 (15 ndash 61)
Male ndash no () 37 (53) 24 (32)
Months in present job class ndash average 28 41
Work hours per week ndash average 318 326
Smoking current ndash no () 16 (23) 12 (16)
History of
Asthma before GWL ndash no () 12 (17) 9 (12)
Hay fever or other non-drug allergies ndash no () 24 (34) 29 (39)
Eczema or atopic dermatitis ndash no () 2 (3) 12 (16)
Exposedindividualsweresignificantlymorelikelythanunexposed individualstoreportwork-relatedrespiratorysymptomsfever bodyachesandeyeandnoseirritationduringthe4weekspriorto surveycompletionasshowninTable4
Table 4 Work-Related Symptomsa Between Exposure Groups Exposed Unexposed Prevalence Ratio Symptom (N = 68 ndash 70) (N = 74) (95 CIb)
no of employees ()
Sore throat 22 (32) 2 (3) 1180 (288 ndash 4831)
Cough 48 (70) 5 (7) 1024 (433 ndash 2423) c
Wheezing 20 (29) 2 (3) 974 (236 ndash 4019) c
Eye irritation 51 (73) 6 (8) 899 (412 ndash 1961)
Fever 14 (21) 2 (3) 762 (180 ndash 3230) Shortness of 26 (38) 4 (5) 670 (247 ndash 1820) c
breath
Chest tightness 19 (28) 3 (4) 667 (208 ndash 2135) c
Body aches 20 (29) 4 (5) 529 (190 ndash 1470)
Nose irritation 33 (48) 10 (14) 354 (189 ndash 662) a Symptoms experienced on the days or evenings that the employee worked within the prior 4 weeks and improving on days off work surveyed March 20 2007 ndash April 2 2007b CI denotes confidence interval c Adjusted for smoking and asthma status
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Results (Continued) Exposedemployeeswerealso58timesmorelikelytoreportan
episodeofchestflu(definedasfeverandcough)orpneumonia sinceemploymentatGWLAmongthosewhoreportedatleast oneepisodetheaveragenumberofepisodeswas23
Allindividualswhoreportedahistoryofasthmadiagnosedbya doctororhealthprofessionalhadasthmabeforeworkingatthe GWLSixofthe10exposedindividualswhostillhadasthma reportedthattheirasthmaseemedworsewhenatworkwhereas noneofthesevenunexposedindividualswhostillhadasthma reportedthattheirasthmawasworseatwork
Theprevalenceofreportedskinrashwithintheprior4weeks was50timeshigherforexposedindividualsthanunexposed individuals(Plt001)Ofexposedindividuals41(2970) reportedhavingaskinrashcomparedto8(673)ofunexposed individualsAmongthelifeguardswhoreportedarashthemost commonlyaffectedareaswereleg(79)arms(34)andtrunk (28)
Daily Symptom Questionnaire
Fourteenof17exposedlifeguardscompletedthedailysymptom questionnaireduringthemorningshiftonhighoccupancyday1 2943duringthemorningandeveningshiftsonhighoccupancy day2and2733duringthemorningandeveningshiftsonthe lowoccupancydayforaparticipationrateof7667and82 respectivelyMostlifeguardsworkingonthehighoccupancydays reportedwork-relatedcoughandeyeirritationasshowninTable 5Nonereportedblurryfoggyorhalovisiononthelowoccupancy dayIncontrastonhighoccupancyday2929(31)reported blurryorfoggyvision
Health Hazard Evaluation Report 2007-0163-3062 Page
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Results (Continued)
Table 5 Daily Work-related Symptomsa Among Exposed Lifeguards
Symptom High Occupancy Day
1 (N = 14)
High Occupancy Day 2
(N = 29)
Low Occupancy Day
(N = 27) no of employees ()
Cough 9 (64) 16 (55) 6 (22)
Eye irritation 9 (64) 20 (69) 9 (33)
Nose irritation 4 (29) 10 (34) 4 (15)
Wheezing 1 (7) 7 (24) 2 (7) Shortness of breath 2 (14) 6 (21) 4 (15)
Chest tightness 3 (21) 5 (17) 0
Sore throat 6 (43) 2 (7) 4 (15) Blurry or foggy vision mdashb 9 (31) 0
Blue-grey vision mdash b 3 (10) 1 (4)
Halo vision mdash b 3 (10) 0 a Symptoms experienced at work starting at beginning middle or end of shift b This information was not collected on the initial version of the questionnaire and therefore is missing for date 32007
Datafromhighoccupancydays1and2wascombinedtocalculate symptomprevalenceratioscomparinghighversuslowhotel occupancydaysWorkingonhighhoteloccupancydayswas associatedwithasignificantlyincreasedriskofexperiencingworkshyrelatedcoughandeyeirritationasshowninTable6
Table 6 Work-related Symptoms a Among Exposed Lifeguards On High versus Low Hotel Occupancy Days
Prevalence Ratio Symptom (95 CIb) Cough 223 (110 ndash 452) c
Eye irritation 196 (122 ndash 317)
Wheeze 243 (050 ndash 1187) c
Shortness of breath 105 (030 ndash 369) c
Nose irritation 216 (083 ndash 559)
Sore throat 127 (046 ndash 351)
Chest tightness undefinedd
a Symptoms experienced at work starting at beginning middle or end of shift b CI denotes confidence interval c Adjusted for smoking status excludes lifeguards having asthma d Undefined indicates that prevalence ratios could not be calculated because no one reported symptoms on the low hotel occupancy day
Page Health Hazard Evaluation Report 2007-0163-3062
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Results (Continued) Nosignificantassociationexistedforblue-greyvisionand
prevalenceratioscouldnotbedefinedforblurryfoggyorhalo visionbecausenoonereportedthosesymptomsonthelow occupancyday
disCussion TheGWLindoorwaterparkisacomplexpoolenvironmentdueto severalfactors(1)thesizeofthecontainedarea(about80000ft2) (2)highwatervolume(415000gallons)andwatersurfaceareaand (3)theamountofwateraerosolizationcausedbysprayfeatures waterslidesetcInadditiontheindoorpoolenvironmentis affectedbyotherfactorsincludingwaterqualitydisinfectantsand theirby-productsnumberofbathersenvironmentalconditions (airandwatertemperatureRHetc)andairhandlingunitdesign andfunctionAlsoindividualfactorsincludingthetimespentby employeesandpatronsinthepoolareaandpersonalsusceptibility toairbornecontaminants(egpreexistingasthmayoungchildren withimmaturerespiratorysystems)canaffecttheseverityof symptomscausedbyDBPsandothercontaminantsControlof symptomscausedbyDBPsandothercontaminantsrequiresa multidisciplinaryapproachincludingairhandlingunitdesign waterchemistrycontrolslimitingaerosolizingsprayfeaturesand poolproceduresandpolicies
Water Water Mixing and Circulation
Thewaterchemistrydifferencesinsomeofthewatersystems canbeattributedtoincompletemixingoftreatedwateroruseof partiallydisinfectedwaterInvestigationintothedifferencesin thewaterchemistryresultsbetweenthepoolandsprayfeatures ofthesamewatersystemshowedthatallthesprayfeaturesdraw waterdirectlyfromthesurgetanksBecausesurgetankwateris thestartingpointofthewaterfiltrationcycleitcouldcontain morecontaminantsthanwatertakenattheendofthefiltration cycleEventhoughthesprayfeaturescontributeaminuteamount ofwatertothepoolanywatercontaminantspresentcouldbe aerosolized
Completeandroutinewaterreplacementinbothhottubsmay havecontributedtotheirlowwaterendotoxinconcentrations Howeverthispracticemaynotbefeasibleforlargerbodiesof
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) wateranddilutionisrecommendedDilutionisamethodof
addingfreshwatertodecreasetheconcentrationofDBPsnot removedbythewatertreatmentsystemTheWHOrecommends adilutionrateof30litersoffreshwaterperbathertodecreasethe concentrationofbather-generatedcontaminants[WHO2006] Adjustmentsoftheseratesneedtoaccountforevaporationrates splash-outelevatedcombinedchlorineandairrecirculationmode CurrentlyGWLdoesnotrecordtheamountofwaterusedto refreshthesystembutislookingatoptionstomeasureandbetter controltheamountofwaterthatisremovedandreplaced
Water Chemistry
Understandingmonitoringandcontrollingwaterchemistryisan importantfactorthatcanlimittheformationofDBPsandtheir migrationfromwaterintotheairSeveraloutbreakinvestigations ofrespiratoryandirritationsymptomsatindoorswimmingpools haveassociatedsymptomswithimproperwaterchemistrycontrol specificallyabnormallevelsofpHandcombinedchlorine[Bowen 2007Kaydos-Daniels2007Safranek2007]Thesestudiesshowed thatthecombinedchlorinelevelsinwaterforthemajorityof outbreakswereelevatedonthedayssymptomswerereportedOne Nebraskapoolhadacombinedchlorineconcentrationofatleast eighttimesthestatersquosmaximumallowablelevelwhensymptoms werereported[Safranek2007]
About80(1417)ofthepoolsurfacewatersamplesandnoneof thehottubsurfacewatermeasuredonMarch202007exceeded theNationalSwimmingPoolFoundationrsquosrecommended maximumcombinedchlorineThehighestcombinedchlorine levelsmeasured04ppmwhichwasnotexceptionallyhigh Howeverthecombinedchlorinevaluefoundinwaterdoesnot takeintoaccounthowventilationsystemsandairmovementaffect thechloraminelevelsintheairAnindoorpoolwithnormal combinedchlorinelevelscanhavehighairtrichloraminelevels ifthereisinsufficientintakeoffreshair[StottmeisterandVoigt 2006]Converselyanindoorpoolwithrelativelyhighcombined chlorinelevelscanhavenormalairtrichloraminelevelsifthe ventilationsystemishighlyefficientThereforeinterpretationof combinedchlorineresultsneedstotakeintoaccountventilation efficacy
ThestateofOhiodoesnothaveacombinedchlorinestandard howeverseveralotherconsensusguidelinesandstandardscanbe
Page 0 Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) usedtocomparethecombinedchlorineconcentrationsmeasured
attheGWL(1)TheCertifiedPool-SpaOperatorHandbook [Ford2007](2)otherstatecodesand(3)theGermanDIN Standard19643[DIN196431997]TheNationalSwimming PoolFoundationrecommendsamaximumcombinedchlorine concentrationof02ppmforpoolsand05ppmforspasand hottubs[Ford2007]Theotherstandardsmentionedhave similarlimitstheGermanDINStandard19643listsamaximum combinedchlorineconcentrationof02ppm[Simonic2003]and severalstateshavecoderegulationsrangingfrom02ppmto10 ppm
Ventilation
Theguidelinesandstandardsdiscussedbelowweredevelopedto provideadequateventilationforstandardstillwater-typepools similartowhatonemightencounteratahotelorothersmall recreationalfacilityTheGWLdesignandactiveaquaticfeatures differgreatlyfromstandardpoolsthereforetheventilation guidelinescurrentlyinplaceforpoolfacilitiesmaynotbesuitable forthisenvironment
Comparison of Ventilation Rates with Consensus Standards and Guidelines
Anumberofdifferentconsensusstandardsandguidelines canbeusedtocomparetheventilationratesusedatthe GWLindoorwaterpark(1)TheASHRAEandtheANSI publicationANSIASHRAEStandard621-2007Ventilation for Acceptable Indoor Air Quality[ASHRAE2007a](2)The2006 WorldHealthOrganizationGuidelinesforSafeRecreational WaterEnvironmentsVolume2Swimmingpoolsandsimilar environments[WHO2006]and(3)The2007ASHRAE Handbook-HVACApplications[ASHRAE2007b]These standardsareperiodicallyupdatedbasedonthelatestscientific researchWhiletheventilationratesusedattheGWLmaymeet onestandardtheymaynotmeetotherguidelinesorstandards
ThestateofOhioincorporatestheoutdoorairventilation requirementsfromANSIASHRAEStandard62Ventilation for Acceptable Indoor Air QualityintotheOhioBuildingCodeand appliesthisstandardtoventilationofindoorpoolfacilitiesThe standardrecommendsminimumventilationratesforacceptable
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) indoorairqualityofenclosedspacesAccordingtothisstandarda
minimumof24literssecondpermeter2(048cfmft2)ofoutdoor airisrecommendedtoventilatepoolanddeckareasofindoorpool facilitiesForGWLthisstandardcorrespondstoapproximately 40000cfmofoutdoorairBasedondesigninformationGWL exceedsthisrequirementbyprovidingaminimumof88000cfm duringmaximumrecirculationoperationThisANSIASHRAE standardventilationrateisbasedontheamountofairbelieved tobesufficienttodilutebuildingandoccupantgenerated contaminantsdowntoanacceptablelevelHoweverrecent researchonairqualityinindoorpoolshasshownthatmany poolsmayhavecomplaintsdespitemeetingtypicalventilation guidelinesTheWHOrecentlyupdatedtheirguidelinesforindoor poolenvironmentstorecommendaminimumof10litersoffresh airpersecondpermeter2ofwatersurfacearea(2cfmft2)[WHO 2006]
The2007ASHRAEHandbook-HVACApplicationsrecommends airexchangeratesbetween4and8ACHforindoorpoolfacilities dependingontheuseofthepoolThenumberofACHisthe ratioofairflowventilationtoroomvolumeGWLprovides 13to20ACHandthereforedoesnotmeetthisASHRAE guidelineTheuseofACHasaperformancestandardfor ventilationsystemshasbeeninplaceformanyyearsHowever itisnotalwaysseenasagoodmeasureofacceptableventilation forallapplicationsAtGWLalargemajorityofthefacilityair volumeisconcentratedinahighbayareaprimarilycomprisedof unoccupiedspaceThereforetherelianceonmeetingaminimum numberofACHmaynotbeapplicableforthissettingHowever theintroductionofmoreoutdoorairmaybenecessaryatGWLto effectivelydilutetheincreasedcontaminantloadduetothelarge numberofwatersprayfeaturesandhighbatherloads
Air Distribution Design
Thedesignoftheair-distributionsystemmaybemoreimportant thanairexchangerateSeveralcriterianeedtobemettoensure comfortwhilestillmaintainingacceptableairqualityFor instancewhilesomeairflowisrequiredacrossthepoolanddeck surfacestheamountofairflowshouldbeminimizedtoprevent draftsonswimmersandtoreduceevaporation[XieandCooper 2006]GeneralASHRAEguidancerecommendspositioning exhaustairinletstomaximizecaptureeffectivenessandminimize recirculationofchloramines[ASHRAE2007b]Chloramine
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) compoundsareheavierthanairandaremorelikelytoconcentrate
closertothepoolsurfaceanddecklevelandsomeairflowis requiredtomovethemtowardsanairreturn
Adequateairflowratesatdeckandpoolsurfacesarenecessaryto movethecontaminantsfromthepooltothereturnductssothey canbeexhaustedfromthebuildingOneofthemajorchallenges withtheairdistributionsystematGWListheplacementofsupply andreturnairdiffusersatheightsof30ndash80ftabovethepooldeck inunoccupiedareasThismaycreateshortcircuitingofairflow fromthesuppliestothereturnsinthehighbayareaTheheight ofthesupplydiffusersabovethedeckalsohinderstheabilityof theventilationsystemtoprovideadequateairmovementatthe pooldeckareaAdditionallytheplacementoffourlargeairreturn ductsapproximately60ndash80ftabovethepooldeckmakesthem poorlypositionedtocaptureandremovecontaminantssuch aschloramineswhichconcentrateatdecklevelanddoesnot promotegoodairmovementintheareasofhighestoccupancy Theuseofcomputer-basedsimulationsmayprovidesomeinsight intothedesignandeffectofchangestotheairdistributionsystem CFDmodelingisananalyticaltoolthatcanprovideadetailed visualdescriptionofthefluidflowheattransferandcontaminant transportBysolvingthefundamentalequationsofconservation ofmassmomentumandenergyaCFDmodelcanprovide informationincludingvelocityfieldstemperaturedistribution andchemicalspeciesconcentrationwithinaregionofinterest CFDcouldbeusedtoanalyzeexistingairflowpatternsandtogain insightintotheeffectofnewdistributiondesigns
WeareawarethatGWLhaschangedtheairdistributionsystemto attempttoaddressconcernswithstagnantairatdecklevelsThese changesincludedloweringthreehighreturnairventstothedeck levelandinstallinghighthrowairdiffusersinselectedareasThe airhandingunitsrsquovolumeofairflowwasincreasedandductwork changesweremadetoincreaseairmovementtothefrontandback areasofthewaterparkGWLestimatesthatafterthesechanges weremade33ofthereturnairistakenfromthehighbayarea and67oftheairispulledfromthelowerreturnairintakes[Zajo 2008b]Thesechangeswerenotevaluatedasapartofthisstudy PriortothesechangesGWLrsquosventilationcontractorperformed qualitativeairflowtesting(usingcommercialfogmachines)inthe poolareatoobserveairflowpatternsNIOSHinvestigatorswere notpresentwhenthefogtestingoccurredandwedidnotreview theresults
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) Air Temperature and Relative Humidity
PocketsofhigherlevelsofRHwereconsistentlyseenthroughout eachsamplingperiodThevariationsweresignificant(P lt001) andmayrepresentpoorairmovementatthedeckleveland potentialbuild-upofcontaminantsPocketsofhighcontaminant concentrationscanoccuratlocationswhereflowisinsufficient tomoveairtotheexhaustductswhereaerosolizationfromspray featuresoccursorwherestructuresmayobstructairmovement
Chloramines and Associated Symptoms
ThetrichloraminelevelsmeasuredattheGWLweresimilarto levelsfoundinotherindoorswimmingpoolstudiesandsomewere atlevelsreportedtocausemucousmembraneirritation[Heryetal 1995Massinetal1998Thickettetal2002Jacobsetal2007] ThesymptomsreportedbyGWLlifeguardsareconsistentwith thoseassociatedwithtrichloramineexposureandwerehigheron dayswhenhoteloccupancywashighHoteloccupancywasused asaproxyforbatherloadandincreasedbatherloadhasbeen significantlyassociatedwithanincreaseintrichloraminelevels [Jacobsetal2007]Twentyfivepercent(416)ofthetrichloramine samplestakenonhighoccupancyday1and20(945)takenon highoccupancyday2exceededaconcentrationof05mgm3the levelatwhichirritationsymptomshavebeendocumented[Heryet al1995]IntheHeryetalstudynoonereportedsymptomsuntil thechloramineconcentrationreached05mgm3andeveryone reportedsymptomswhenthelevelsreached07mgm3Inanother studyinvolving334lifeguardsand63indoorpoolstheprevalence ofmucousmembraneirritationamonglifeguardsexposedto trichloraminelevelsabove05mgm3was86foreyeirritation 61noseirritation29throatirritationand42drycough [Massinetal1998]Jacobsetalmeasuredtrichloraminelevelsat sixindoorswimmingfacilitiesandfoundanelevatedprevalenceof respiratorysymptomsinswimmingpoolworkersTheymeasureda meantrichloramineconcentrationof056mgm3withthehighest concentrationreaching134mgm3Generalrespiratorysymptoms weresignificantlyhigherinpoolemployeescomparedtotheDutch populationsample(oddsratiorangedfrom14to72)[Jacobsetal 2007]
Basedonconcentration-responsedatainmiceGagnaire etal recommendedaSTELof15mgm3andaTWAof05mgm3for
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) trichloramine[Gagnaireetal1994]ATWAexposurereferstothe
averageairborneconcentrationofasubstanceduringanormal8- to10-hourworkdayAlthoughproposedstandardsandpaststudies indicatethatacomfortlevelforindoorpoolareaswouldbetokeep trichloramineconcentrationsbelow05mgm3therehavebeen someconcernsthatthislevelmaynotbelowenoughtoprevent symptoms[Massinetal1998]Astudycomparingtheprevalence ofhealthcomplaintsbetweenteenageswimmersandsoccer playersshowedasignificantincreaseinrespiratorycomplaintsat chloramineconcentrationsof037mgm3orgreater[Levesque etal2006]TheWHOrecommendsusinganairtrichloramine concentrationof05mgm3asaprovisionalvaluealthoughit statesthatmoreresearchisneededtoinvestigatehealtheffectsin peoplewhousethepoolforextendedperiodsoftimeandtherole oftrichloramineinpossiblycausingorexacerbatingasthma[WHO 2006]
Properairmovementanddistributionplayakeyroleinreducing chloramineconcentrationsandhealtheffectsIn1983an occupationalmedicinephysicianreportedaswimmerwho developedcoughingandwheezingonlywhenvisitingapool equippedwithanautomaticallycontrolledheatreclamationsystem [Penny1983]Symptomswereworseinthewintermonthswhen theheatreclamationsystemrecirculatedahigheramountofairto conserveenergyThepatienthadnorespiratorysymptomswhen hevisitedanolderpoolwithasimpleairextractorSpirometry demonstrateda24to33dropinforcedexpiratoryvolumein 1secondafterswimminginthenewpoolcomparedtoa6drop inforcedexpiratoryvolumein1secondafterswimminginthe olderpoolThephysiciansuspectedthattrichloraminecausedthe respiratorysymptomshowevernoacceptedmethodformeasuring trichloramineintheairwasavailableatthattime
Recentstudieshaveraisedquestionsaboutwhetherinhalation ofDBPsmaycauseorexacerbateexistingasthmaAstudyoftwo lifeguardsandaswimminginstructorshowedthatswimmingpool asthmacanoccurinworkerswhoareexposedtochloraminesThe researchersgeneratedtrichloraminesat05mgm3inachallenge chamberandexposedtheparticipantstoaseriesof10-minute exposuresfollowedbyspirometryResultsshowedadecreasein pulmonaryfunction[Thickettetal2002]Additionallynew researchindicatesthattheremaybeothervolatileDBPswith potentiallyirritantpropertiesinindoorpoolenvironments[Li 2007]
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion Waterattractionsthatcreatesurfacewaterdisturbancescan (Continued) increaseaerationofwatercontaminantsWefoundhigher concentrationsoftrichloramineinareasaroundtheleisureriver wherethereiscontinuouswatermovementandsplashingThis attractioncontainsahighwater-to-airsurfaceareainconstant motionwhichcanaccelerateevaporationAstudyconductedat anindoorswimmingpooldemonstratedthattheoperationof awaterslideincreasedthenumberofrespirableparticlesby23 foldandthatnumberincreasedby52foldwithfullwaterfeature use[Roseetal1998]Otherstudieshavelookedatchloramine concentrationdifferencesbetweenindoorleisurepools(pools containingwater-disturbingfeatureslikeslides)andstillwater poolsInonestudymeantrichloraminelevelswere024mgm3 atstillwaterpoolsand067mgm3atleisurepools[Massinetal 1998]Heryetalalsoreportedthatairchloramineconcentrations werehigherinleisurepoolsduetotheinfluenceofslidesbubbling bathswavesandotherwateractivities[Heryetal1995]
Systemic Symptoms
Lifeguardsweremorelikelytoreportwork-relatedcough feverandbodyachesaswellaschestfluwithfeverandcough orpneumoniasinceemploymentatGWLThesesymptoms togetherareconsistentwithhypersensitivitypneumonitis Hypersensitivitypneumonitisisarareconditioncausedbyinhaling foreignsubstancesThesesubstancescausethelungstobecome inflamedInindoorpoolenvironmentsthisconditioncanbe causedbyinhalationofbioaerosolssuchasendotoxinTheair endotoxinlevelsmeasuredatGWLwereseveraltimeshigherthan backgroundlevelsandexceededtheproposedACGIHRLVfor endotoxinexposure(seeAppendixC)Theaverageairendotoxin concentrationfoundatGWL(45EUm3)wascomparabletothe averageconcentrationsmeasuredduringsequentialoutbreaksof hypersensitivitypneumonitisatanindoorswimmingpoolwith watersprayfeaturesndash76EUm3duringthefirstoutbreakand28 EUm3duringthesecondoutbreak[Roseetal1998]
Apriorstudyoflifeguardsconcludedthathypersensitivity pneumonitiswasassociatedwithendotoxin-containingrespirable bioaerosolsgeneratedbywatersprayfeaturesFulluseofthewater featuresatthatpoolfacilityresultedina35to8foldincrease inmeanairendotoxinconcentrations[Roseetal1998]Water collectedfromthesprayfeaturesatthepoolgrewGram-negative bacteriawhichwaspresumedtobethesourceofendotoxinAt
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) thisindoorswimmingpooleliminatingbacteriafoundinside
thesprayfeatureswaskeytodecreasingairendotoxinlevelsand symptoms
Skin Rash
GWLpatronsraisedquestionswhetherallergiestosulfa medicationswouldcausethemtohaveallergicskinreactions whenexposedtowatercontainingsulfuricacidSulfuricacid canbreakdowntosulfatesHoweveritishighlyunlikelythat theskinrashreportedbythelifeguardsisduetoasulfateallergy Sulfateallergiesareextremelyrareandsulfatesaresocommon thatmostpeoplehavebeenexposedtothemearlyinlife(ie sulfatesarecontainedinmostpersonalhygieneproducts) Additionallythemostcommonldquosulfurallergyrdquoassociatedwith medicationisduetosulfonamidewhichischemicallydistinct fromsulfates[Strometal2003]
WedidnottestforPseudomonasbacteriabecausethereported skinrashesdidnothavethetypicalcharacteristicoffolliculitisor Pseudomonasinfection
Themostcommonareasofskinrashreportedamongthe lifeguardsinvolvedthelegarmandtrunkTheseareasare mostfrequentlyexposedtoldquowetworkrdquowheretheskinisin waterPossibleoccupationalskinirritantsincludeheatwater andchlorinecompoundsSeverallifeguardsreportedarash betweenthethighsandintheabdominalskinfoldstheseareas tendtoremainwarmandmoistWatercanalsobeanirritant withchronicexposureandwater-inducedcontactdermatitis amongwetworkerssuchashairdressershospitalcleaners hydrotherapistsandbartendersiswelldocumentedinthe occupationaldermatologyliterature[Tsai1999Lazarov2005 Pardo2007]GWLlifeguardsrotatethroughseveralstations andattimesstandimmersedinwateruptowaistlevelto catchbatherstubesexitingfromthewaterslidesOftentimes theirbathingsuitsremainwetthroughoutanentireshiftIn additiontowaterexposurelifeguardsareexposedtochlorine compoundsinthewaterTherehavebeenafewcasereports ofcontactdermatitisassociatedwithswimminginchlorinated poolwater[Neering1977Sasseville1999]Howeverfewformal epidemiologicalstudiesexistandtheprecisemechanismhas notbeenelucidatedInarecentcross-sectionalstudyofchildren swimmingineitherchlorinatedorbrominatedpools4ndash8
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) ofrespondentsdevelopedaskinrashwithin24hoursofpooluse
[Kelsall2001]Thesecasereportsandstudiessuggestthatseveral environmentalexposuresinsidetheindoorpoolareaincluding heatwaterandchlorinecompoundsallcancontributetothe higherrateofskinrashobservedamongthelifeguards
Visual Symptoms
Severallifeguardsreportedblurryblue-greyandorhalovision whileatworkAllreportedthatthevisualchangesweremostsevere duringthecoldwintermonthsWhileblurryvisioncouldbea reflectionofeyeirritationhalovisionismuchmoreunusualA varietyofaminecompoundshavebeenreportedtocausesimilar visualsymptomsForexampleaNIOSHinvestigationofblurry haloandblue-greyvisionatalabelprintingfacilitylinkedthe symptomswithexposuretoatertiaryaminecompoundInthat investigationcornealopacitywasthecauseofthesymptomsand appearedtobeduetodirectdepositionoftheaminecompound ontothecornea[Pageetal2003]Weofferedtohavethesame ophthalmologistwhoperformedtheeyeexamsinthelabelprinting healthhazardevaluationexaminelifeguardswithblurryorhalo visiontodetermineiftheyhadcornealopacityHoweveratthe timethequestionnaireswereadministeredtheenvironmental conditionsweremuchdifferentfromwhenvisualsymptoms reportedlypeakedAsaresultwemaynothavecapturedvisual symptomsduringatimeofpeaktrichloramineexposureandno lifeguardsreportedthesymptomswhentheophthalmologistwas availableInadditiontrichloraminediffersfromthetertiaryamine intheprevioushealthhazardevaluationbecausetrichloramineis inorganicandinsolubleinwater
Limitations
Duetoconcernthatthesamplingequipmentwouldinterfere withthelifeguardsrsquorescuedutiesandgetwetwedidnotmeasure personalexposurestochloraminesandendotoxinThislimited ourabilitytoevaluateanypossibleassociationbetweenchloramine concentrationsandreportedsymptomsAlsothedraftNIOSH chloraminesamplingandanalyticalmethodisstillindevelopment BecauseofthewidedifferencesintheLODsandLOQsforeach dayofsamplingwecouldnotcomparethedataacrossallsampling daysConcentrationsthatwereconsideredabovetheLOQone daymayhavebeenbelowtheLODonanotherdayTherefore
Page Health Hazard Evaluation Report 2007-0163-3062
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
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Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) observationscouldonlybemadewithdatafromwithinasampling
day
Outdoorenvironmentalconditionssignificantlydifferedbetween theperiodofpeakhealthcomplaints(JanuaryandFebruary) andthedaysthatNIOSHsamplingoccurredTheoutdoor temperatureaveraged35ordmFinJanuaryand20ordmFinFebruary Whenoutdoortemperaturesarebelow40ordmFtheairhandling systemstartsrecirculatingindoorairIncontrasttheoutdoor temperatureremainedabove40ordmFduringoursamplingperiods inMarch(monthaverage49ordmF)andApril(monthaverage52ordmF) BecauseindoorairwasnotrecirculatedduringthedatesofNIOSH samplingthetrichloramineandsolublechlorinelevelsmeasured inthisstudymaynotrepresenttheconcentrationspresentattime ofinitialreportsofsymptomsAlsobecauselifeguardsreported thattheirsymptomshadimprovedsignificantlywiththewarmer weatherthesymptomdatacapturedduringthisinvestigationmay notrepresentwhatthelifeguardsmighthaveexperiencedduring thecoldermonthswhenindoorairwasrecirculated
Alimitationoftheventilationassessmentwasthedifficulty intakingairflowmeasurementsStandardairflowevaluation techniquessuchastheuseofsmokevisualizationandtracergas testingweredifficultgiventhecomplexityandlargesizeofthe waterparkInsteadairhandlingsystemdesignswerereviewedto identifywaystoincreaseairmovementatthedecklevel
EnvironmentalandproceduralchangesmadefromJanuaryto MarchbyGWLinresponsetopatronhealthconcernscould havecontributedtoreducingaircontaminantconcentrationson thedayswesampledcomparedtowhenthesymptomswerefirst reportedAlsothenumberofbathersmayhavevariedfromwhen reportedsymptomspeaked(JanuaryFebruary)andoursampling days
Aroundthetimeofsurveycompletionthemediareported ontheoccurrenceofrespiratoryandskinsymptomsatGWL Becauseoftheheightenedawarenessrecallbiasmayhavebeen introducedintotheinitialquestionnaire(lifeguardsmayhave beenmoreinclinedtorecallsymptomsthanemployeesworking outsidethewaterparkarea)Alsoasthmaticsmaybemorelikely totakeupswimminginsteadofothersportsbecauseswimming isconsideredasportthatislesslikelytocauseexercise-induced asthmaThereforeswimmersmaybemorelikelytohaveasthma
Health Hazard Evaluation Report 2007-0163-3062 Page
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
disCussion (Continued) thanpeoplewhoparticipateinothersportsHowevercomparison
ofwork-relatedsymptomsamonglifeguardsondifferentdates shouldminimizethispotentialbiasandthecompletionofthe dailysymptomquestionnaireimmediatelyattheendoftheirshift shouldminimizerecallbias
Becauseonly68oflifeguardsfilledouttheinitialquestionnaire participationbiasmayhaveoccurredInadditionbecauseseveral lifeguardswerereportedtohavequitwithinthestudyperioddue towork-relatedsymptomsourresultsmayunderestimatethe prevalenceofsymptoms
ConClusions BasedonourreviewoftheventilationsystemRHand trichloraminemeasurementstheventilationsystematthetimeof ourevaluationmaynotbeprovidingsufficientairmovementand distributiontoallowadequatecaptureandremovalofchloramines atthepoolsurfaceanddecklevelsVentilationdesignconcerns includetheplacementofairsupplydiffusersandreturnairinlets atheightsof30ndash80ftabovedecklevelmakingitdifficultto providesufficientairmovementatthepoolsurfaceanddecklevels andcreatingthepotentialforshortcircuitingofsupplyairtothe exhaustductsAlsorecirculatingairduringtimesofhighbather loadmayincreaseconcentrationsofcontaminantsintheairThe factthatthefacilityrsquosoverallairexchangerateismuchlowerthan recommendedbyASHRAEisalsoaconcern
Trichloramineconcentrationsmeasuredweresimilartolevels foundinotherindoorswimmingpoolstudiesandsomewereat levelsreportedtocauseirritationsymptomsExposedindividuals weresignificantlymorelikelythanunexposedindividualsto reportwork-relatedrespiratorysymptomseyeandnoseirritation feverbodyachesandskinrashesinthe4weekspriortosurvey completionTheprevalenceofwork-relatedcoughandeye irritationamongtheexposedindividualswassignificantlyhigher ondayswhenhoteloccupancywashigh
ThewaterchemistrytestresultsatGWLmetOhiostatestandards andnoLegionellamycobacteriaorfecalcoliformbacteriawere foundinanywatersamplesAirborneendotoxinlevelsinallpool areasexceptthewaterfortexceededtheproposedACGIHRLV forendotoxinexposureandweremeasuredatlevelsthathavebeen associatedwithcoughandfever
Page 0 Health Hazard Evaluation Report 2007-0163-3062
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
ReCommendAtions Air Distribution System
Properventilationdesignisakeycomponenttoreducingthe levelsofairborneDBPssuchaschloraminesToaddressconcerns ofstagnantairatdecklevelGWLmodifiedtheairdistribution systembasedinpartonNIOSHrecommendationsmadeafter theinitialventilationdesignreviewWhilethechangestotheair distributionsystemmayhelpaddresstheissuesdiscussedinthis reportincludingairmovementandcontaminantremovalatthe poolsurfaceanddeckleveltheeffectofthesechangeswerenot evaluatedasapartofthisstudyThereforewerecommendthat GWLconductanevaluationoftheairdistributionsystemto determinetheeffectofthechangesmadeincluding
1 Considermeasuringdecklevelairvelocityaswell asroutinelymonitoringindirectmeasuresofsystem performancesuchastemperatureandRHatavarietyof locationsthroughoutthefacilitytohelpassessventilation effectiveness
2 Considerconductingventilationtestingsuchasair visualizationteststohelpidentifypotentialstagnantareas withinthefacility
3 ConsiderusingCFDmodelingtoevaluatetheimpact ofanyairdistributionsystemchangesonairmovement CFDisatoolthatmightbeusefultosimulatetheeffect ofanychangesonaircirculationpatternsandventilation efficiency
4 Evaluatethefacilityagainduringcoldweathertoassessthe airqualityduringtimesofhighbatherloadandlowoutdoor temperatures(whenmaximumairrecirculationoccurs)
5 Considerincreasingtheairexchangerateifimprovements inairdistributiondonotadequatelyreducechloramineand endotoxinlevels
Water System
1 Keepcombinedchlorinelevelsaslowaspossibleand continuetomaintainwaterchemistrywithinrecommended guidelines
2 Increasetheamountoffreshwaterexchangebasedon batherloadtodilutecontaminantsinthewater
Health Hazard Evaluation Report 2007-0163-3062 Page
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
ReCommendAtions (Continued) 3 Continuetoconductwaterchemistrychecksatpoolside
andcomparereadingstotheChemtrolmonitortoensure accuracyandconsistency
4 Takemultiplereadingsatvariouspoolsidelocationswithin eachwatersystematdifferenttimesofdayandatdifferent batherloadsasoftenasnecessarytofullycharacterizethe consistencyofwaterchemistryAlsomonitorwaterquality collectedfromsprayfeaturesregularlytoensuretheyare consistentwithstatestandardsandindustryguidelines
5 Considerredesigningthesprayfeaturepipingsystemtotake waterdirectlyafterthefiltrationandtreatmentcycle
6 Reducethegenerationofairbornerespirableparticlesby implementingthefollowing
a Usespraynozzlesthatproducelargerdropletswhich mayhelpreduceevaporationandaerosolizationofDBPs andbioaerosols
b Reducethecycletimeofwaterfeaturesthataerosolize water(largebucketdumpswavesetc)
7Developdisinfectionchemistrytrendsovertimeusingthe controllersrsquodataloggingfeaturesThesetrendscanhelp identifycontributingfactorsthatoccurwhensymptomsare reported
Procedure and Policy
1 Provideeducationandtrainingtoemployeesonrecognizing thesymptomsandsignsofeyeandrespiratoryirritation skinrashandasthma
2 Encourageemployeestoreportsymptomstomanagement earlyifneededreferemployeestoaphysicianpromptly
3 Keepalogofemployeesymptomsrelatedtoworkinginside theindoorpoolareaandperiodicallyreviewthelogsto lookfortrends
4 Educatepatronsontakingshowersbeforeenteringandafter leavingthepoolareaminimizingtimespentinthepool areaandencouragingchildrentouserestroomfacilities ratherthanurinatinginthepool
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
RefeRenCes ASHRAE[2007a]VentilationforAcceptableIndoorAirQuality ANSIASHRAEstandard621-2007AtlantaGAAmerican SocietyofHeatingRefrigeratingandAir-ConditioningEngineers Inc
ASHRAE[2007b]HeatingVentilatingandAir-Conditioning ApplicationsASHRAEHandbookAtlantaGAAmericanSociety ofHeatingRefrigeratingandAir-ConditioningEngineersInc
BarbeeSJThackaraJWRinehartWE[1983]Acuteinhalation toxicologyofnitrogentrichlorideAIHAJ44(2)145ndash146
BowenABKileJCOttoCKazerouniNAustinCBlount BCWongHNBeachMJFryAM[2007]Outbreaksofshortshyincubationocularandrespiratoryillnessfollowingexposureto indoorswimmingpoolsEnvHealthPers115(2)267ndash271
DIN19643DeutscheNormAufvereitungvonSchwimm-und BadebeckenwasserTeil12und3DINDeutschesInstitutfur NormungeVBeuth-VerlagBerlin1997
DziubanEJLiangJLCraunGFHillVYuPAPainterJMoore MRCalderonRLRoySLBeachMJ[2006]Surveillancefor waterborne-diseaseoutbreaksassociatedwithrecreationalwater mdashUnitedStates2003ndash2004MMWR55(SS12)1ndash24
FordRL[2007]Certifiedpool-spaoperatorhandbook Colorado SpringsCONationalSwimmingPoolFoundation
GagnaireFAximSBonnetPHechtGHeryM[1994] Comparisonofthesensoryirritationresponseinmicetochlorine andnitrogentrichlorideJApplToxicol14405ndash409
GunkelKJessenHJ[1988]Theproblemofureainbathingwater ZGesamteHyg34248ndash249
HeryMGerberJMHechtGSubraIPossozCAubertS DieudonneMAndreJC[1998]Exposuretochloraminesina greensaladprocessingplantAnnOccupHyg42(7)437ndash451
HeryMHechtGGerberJMGendreJCHubertGRebuffaud J[1995]Exposuretochloraminesintheatmosphereofindoor swimmingpoolsAnnOccupHyg39(4)427ndash439
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
RefeRenCes (Continued) HolzwarthGBalmerRGSoniL[1984]Thefateofchlorineand
chloraminesincoolingtowersWaterRes18(11)1421ndash1427
JacobsJHSpaanSvanRooyGBMeliefsteCZaatVA RooyackersJMHeederikD[2007]Exposuretotrichloramineand respiratorysymptomsinindoorswimmingpoolworkers EurRespirJ29(4)690ndash698
Kaydos-DanielsSCBeachMJShweTMagriJBixlerD[2007] Healtheffectsassociatedwithindoorswimmingpoolsasuspected toxicchloramineexposurePublicHealthEpub2007Jun25
KelsallHSimM[2001]Skinirritationinusersofbrominated poolsIntJEnvironHealthRes11(1)29ndash40
LazarovANevoKPardoAFroomP[2005]Self-reportedskin diseaseinhydrotherapistsworkinginswimmingpoolsContact Dermatitis53(6)327ndash331
LevesqueBDuchesneJFGingrasSLavoieRPrudrsquoHomme DBernardEBouletLPErnstP[2006]Thedeterminants ofprevalenceofhealthcomplaintsamongyoungcompetitive swimmersIntArchOccupEnvironHealth80(1)32ndash39
LiJBlatchleyE[2007]Volatiledisinfectionby-productformation resultingfromchlorinationoforganicndashnitrogenprecursorsin swimmingpoolsEnvironSciTechnol41(19)6732ndash6739
MassinNBohadanaABWildPHeacuteryMToamainJPHubert G[1998]Respiratorysymptomsandbronchialresponsivenessin lifeguardsexposedtonitrogentrichlorideinindoorswimming poolsOccupEnvironMed55(4)258ndash263
NeeringH[1977]Contacturticariafromchlorinatedswimming poolwaterContactDermatitis3(5)279
NeumanC[2007]TelephoneconversationonAugust142007 betweenCNeumanWaterTechnologyIncFGonzalesGreat WolfResortsandKDunnDivisionofAppliedResearchand TechnologyNationalInstituteforOccupationalSafetyandHealth CentersforDiseaseControlandPreventionUSDepartmentof HealthandHumanServices
Page Health Hazard Evaluation Report 2007-0163-3062
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
RefeRenCes (Continued) NIOSH[2003]Hazardevaluationandtechnicalassistancereport
Bil-MarFoodsIncStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2002shy0257-2916
NIOSH[2006]Hazardevaluationandtechnicalassistance reportSaraLeeFoodsStormLakeIACincinnatiOHUS DepartmentofHealthandHumanServicesPublicHealthService CentersforDiseaseControlandPreventionNationalInstitutefor OccupationalSafetyandHealthNIOSHHETAReportNo2006shy0153-3022
OhioDepartmentofHealth[2003]Disinfectionandqualityof waterInPublicSwimmingPoolsPublicSpasandSpecialUse Pools[httpwwwodhohiogovrulesfinalf3701-31aspx]Date accessedNovember202007
OhioFireCode[2006]MaximumOccupancyPermitin accordancewith13017-7-10(D)(3)Section10043
PageEHCookCKHaterMAMuellerCAGroteAAMortimer VD[2003]Visualandocularchangesassociatedwithexposureto twotertiaryaminesOccupEnvironMed6069ndash75
PardoANevoKVigiserDLazarovA[2007]Theeffectof physicalandchemicalpropertiesofswimmingpoolwaterandits closeenvironmentonthedevelopmentofcontactdermatitisin hydrotherapistsContactDermatitis50(2)122ndash126
PennyPT[1983]SwimmingpoolwheezingBrMedJ 287(6390)461ndash462
RoseCSMartynyJWNewmanLSMiltonDKKingTEBeebe JLMcCammonJBHoffmanREKreissK[1998]ldquoLifeguard lungrdquoendemicgranulatomouspneumonitisinanindoor swimmingpoolAmJPublicHealth88(12)1795ndash1800
SafranekTSemerenaSHuffmanTTheisMMagriJTorokT BeachMJBussB[2007]Ocularandrespiratoryillnessassociated withanindoorswimmingpoolmdashNebraska2006MMWR 56(36)929ndash932
Health Hazard Evaluation Report 2007-0163-3062 Page
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
RefeRenCes (Continued) SassevilleDGeoffrionGLowryN[1999]Allergiccontact
dermatitisfromchlorinatedswimmingpoolwaterContact Dermatitis41(6)347ndash348
SimonicM[2003]BathingwaterconditioningActaChimica Slovenica50587ndash591
StottmeisterEVoigtK[2006]Trichloramininderhallenbadluft ArchivdesBadewesens3158ndash162
StromBSchinnarRApterAMargolisDLautenbachE HennessySBilkerWPettittD[2003]Absenceofcross-reactivity betweensulfonamideantibioticsandsulfonamidenonantibiotics NEJM349(17)1628ndash1635
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002] OccupationalasthmacausedbychloraminesinindoorswimmingshypoolairEurRespirJ19827ndash832
TsaiTFMaibachHI[1999]HowirritantiswaterAnoverview ContactDermatitis41(6)311ndash314
WHO[2006]Guidelinesforsaferecreationalwaterenvironments Volume2SwimmingpoolsandsimilarenvironmentsGeneva SwitzerlandWorldHealthOrganization
XieLCooperK[2006]NatatoriumstheinsidestoryASHRAE Journal48(4)16ndash27
ZajoT[2008a]NIOSHresponse31008docDocumentsentto LiliaChenMarch102008
ZajoT[2008b]07MasonVentilationChangesdocDocument senttoLiliaChenMarch202008
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix A tABles
Table A1 Water Chemistry ndash High Occupancy Day 1
Feature Chlorine (ppm) Sample Location No pH Free Combined
Leisure river 1 75 10 04 2 74 12 04 3 72 12 04 4 72 12 03
Wave 5 74 12 04 6 72 12 03 7 74 15 04
Activity 8 73 13 02 9 72 14 04 10 73 12 03 11 73 10 03
Waterfort 12 76 10 02
Repeata 74 10 03 13 72 12 02
Childrens 14 70 18 04 15 73 22 04 16 78 18 03
Adult hot tub 17 76 20 02 18 73 30 02
Family hot tub 19 71 25 04 20 72 35 04
a A repeat measurement was taken at location 12
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix A tABles (Continued)
Table A2 Free and Combined Chlorine Concentrations in Water a
High Occupancy Day 1 High Occupancy Day 2 Low Occupancy Day Location
Free b Combined c Free b Combined c Free b Combined c
Activity pool 14 01-03 16 02-04 18 0-02 Leisure river 10 01-05 12 03-07 26 005-03 Childrens pool 24 03-04 10 04-05 18 01-02 Wave pool 14 0-04 20 02-06 18 0-02 Adult hot tub 20 02-04 30 02-03 36 0-02 Family hot tub 24 02-04 18 03-07 34 0-02 Waterfort 18 02-04 20 02-05 18 0-01 a All concentrations reported in ppm Data taken from the GWLrsquos Daily Air and Water Quality Logs b Measurements taken poolside at opening with DPD test kit c Measurements taken at valves near Chemtrol system with DPD test kit
Table A3 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 1 Trichloramine Concentration (mgm3)Location 9 amndash1 pma 1 pm ndash 5 pma Meanb
Spirit Island food stand 036 ND 028 Lily pad pond 047 037 043 Leisure river by stairs 064 049 057 Top of slide tower 046 035 041 Splash pool by turn slide c 066 049 057 Adult hot tub by exhaust 055 038 047 Wave pool 061 042 052 Towel rack 039 039 039 Meanb 051 037 044 ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average c Pump was damaged in the field so post-calibration reading was not possible To estimate post-calibration flow we incorporated the average percent error measured by the rest of the pre- and post-calibrated pumps to obtain a post-calibration flow
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix A tABles (Continued)
Table A4 Soluble Chlorine Air Concentrations by Location and Time ndash High Occupancy Day 2 Soluble Chlorine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meane
Spirit Island food stand 009 017 018 020 020 018 Lily pad pond 009 019 020 017 020 018 Leisure river by stairs Top of slide tower
019 009b
020 018
021 016
024 021c
015 021
021 017
Splash pool by turn slide 018 025 021 025 014 022 Adult hot tub by exhaust 009 020 020 020 019 019 Wave pool 009 021 023 021 023 020 Towel rack 009 016 016 015 018 015 Waterfort 009 011d 013 011 009 011 Meane 011 019 019 019 018 018 Values in bold are between the LOD and LOQ a Approximate times b Back portion of sample was lost c Pump failed Sampled for 43 minutes d Small amount of sample lost in transfer e Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Table A5 Trichloramine Air Concentrations by Location and Time ndash High Occupancy Day 2 Trichloramine Concentration (mgm3)
Location 7 amshy9 ama
9 amshy1 pma
1 pmshy5 pma
5 pmshy9 pma
9 pm- 11 pma
Meanb
Spirit Island food stand ND 040 043 042 041 038 Lily pad pond ND 078 088 083 060 072 Leisure river by stairs 009 077 093 106 074 080 Top of slide tower ND 039 045 ND 047 036 Splash pool by turn slide ND 075 090 089 070 073 Adult hot tub by exhaust ND 041 044 043 044 038 Wave pool ND 041 085 086 054 061 Towel rack ND 041 077 086 054 059 Waterfort 009 043 087 081 072 064 Mean b 007 053 072 076 057 058 Values in bold are between the LOD and LOQ ND = Non detectable (below the LOD)a Approximate times b Used LODSQRT(2) for values below the LOD Means were calculated by taking a time-weighted average
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
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Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix A tABles (Continued)
Table A6 Endotoxin Air Concentrations by Location ndash High Occupancy Day 2 Concentration Location Time (min) (EUm3)
Wave pool 500 84 Leisure river by stairs 422 67 Splash pool by turn slide 506 50 Lily pad pond 504 50 Adult hot tub by exhaust 508 46 Towel rack 509 42 Spirit Island food stand 503 25 Top of slide tower 489 25 Waterfort 507 18 Control ndash administrative office 510 2 Mean a 494 45 a Mean excludes control sample in administrative office
Table A7 Endotoxin Water Concentrations by Location ndash High Occupancy Day 2 Concentration Location (EUmL)
Surge tank ndash leisure river 77 Leisure river 76 Wave pool by mushroom fountain 61 Childrenrsquos pool 59 Surge tank ndash childrenrsquos pool 52 Control ndash womens room tap water 28 Activity pool 26 Waterfort 25 Family hot tub 19 Control ndash mens room tap water 15 Adult hot tub 054 Mean a 44 a Mean excludes control samples
Table A8 Mean Temperature and Relative Humidity
Location High Occupancy Day
1 High Occupancy Day
2 Low Occupancy Day
(F) () (F) () (F) () Spirit Island food stand Lily pad pond Leisure river by stairs Top of slide tower Splash pool by turn slide Adult hot tub by exhaust Wave pool Towel rack Waterfort
87 85 84 88 85 85 86 83
Nonea
43 62 68 46 59 57 60 63
Nonea
84 84 83 88 83 84 86 82
NAb
46 58 60 44 57 51 54 69
NAb
86 85 84 89 85 85 86 83 83
44 50 57 41 54 57 54 63 68
Mean 85 57 84 55 85 54 a No readings were taken at this location b Recording device failed at this location due to excessive water
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix B metHods
Chloramines
Asamplingpumppullsairthroughasorbenttubethattrapssolublechlorinecompoundsontosilica gelcoatedwithsulfamicacidSolublechlorinecompoundsincludemonochloraminedichloramine hypochloriteandhypochlorousacidTheairthenpassesdirectlyfromthesorbenttubethrougha37shymmpolystyrenecassetteloadedwithtwoquartzfiberfilterscoatedwithsodiumcarbonateanddiarsenic trioxidetocapturetrichloramine
TheairsampleswerecollectedusingcalibratedAircheckTM2000samplingpumps(SKCEightyFour Pennsylvania)ataflowrateof10literperminuteThesamplingpumpswerepre-andpost-calibratedwith aDryCalregDCLiteprimaryairflowmeter(BiosInternationalCorpButlerNewJersey)Sampleswere refrigeratedinthedarkandanalyzedwithin6daysofcollection
Foranalysisofthesorbenttubesthesamplesweredesorbedbyplacingtheimpregnatedsilicagelfrom thetubeintoa20mLvialTenmLofa10gLsulfamicacidsolutionwasaddedtoeachvialandthe sampleswereperiodicallyagitatedfor30minutesThesampleextractsweredecantedintoanothervial andrefrigerateduntilanalysisSampleswereanalyzedforchlorinebyinductivelycoupledplasmandashatomic emissionspectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedfor eachsampleset
Duringanalysisofthefilterseachfilterwasremovedfromthecassetteandplacedina20mLsample vialAfter10mLofdeionizedwaterwasaddedthesampleswereperiodicallyagitatedfor30minutes Sampleswererefrigeratedandfilteredpriortoanalysisbyinductivelycoupledplasmandashatomicemission spectroscopyatawavelengthof134724nanometersTheLODandLOQweredeterminedforeach sampleset
SamplingcollectionandanalysiswasperformedaccordingtotheNIOSHdraftmethodwhichwas adaptedfromtheINRSmethod[INRS2007]
Endotoxin
Airsampleswerecollectedusinganendotoxin-free3-piece37-mmclosed-facecassettepreloadedwith045 micrompore-sizefiltersSampleswerecollectedwithAirCheck2000personalairsamplingpumpscalibrated at2litersminutepre-andpost-shiftwithaDryCalDCLiteprimaryairflowmeterWatersampleswere collectedwithsterilescrew-capcontainersfreeofdetectableendotoxinandsenttothelabforanalysis EndotoxinanalysiswasperformedbyAerotechPampK(CherryHillNJPhoenixAZ)Sampleswere analyzedforendotoxincontentwiththeKinetic-QCLreginstrumentationusingtheLALassay[Cambrex 2005]Fortheseanalyses6EUareequivalenttoonenanogramofendotoxinTheLODwas0005EU persample
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
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Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
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Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix B metHods (Continued)
Microbials
BulksamplesweretakenforLegionellamycobacteriaandfecalcoliformbacteriaFormicrobialsbulk watersamplesof100mLwerepouredintosterilebottlescoatedwithsodiumthiosulfatepreparedbythe contractlabSampleswerekeptcoldandinthedarkuntilanalysisAnalysisforLegionellamycobacteria andfecalcoliformbacteriawasperformedbyMicrobiologySpecialistsInc(HoustonTexas)TheColilert testprocedurewasperformedtotestfortotalcoliformsandEscherichia coli inwaterReagentwasadded to100mLofsamplewaterandincubatedfor24hoursAcolorchangeindicatedthepresenceoffecal coliformbacteriaAcolorchangethatfluorescesunderaUVlampindicatedthepresenceof Escherichia coliFormycobacteriaanalysisthesampleswereconcentratedwithacentrifugeTheconcentratewasthen placedinaBactechsystemandmonitoredweeklyfor6weeksSimultaneouslythesampleswereplatedon 7H10agarandculturedLegionellasampleswerecentrifugedplatedonbufferedcharcoalyeastextractagar andculturedfor7to10days
Sulfites and Sulfates
WatersamplesforsulfitesandsulfatesweretakeninsterilizedcontainerswithnoheadspaceAllbulk sampleswereplacedincoolersandstoredintherefrigeratoruntilpackagedoniceandshippedtothe analyticallaboratoryEachsamplewasfilteredusinga045micron25mmsyringefilterattachedtoa10 mLsyringeSulfatesandsulfiteswereanalyzedusingaDionexDX-120ionchromatographSampleswere analyzedusingtheEnvironmentalProtectionAgencyMethod3000[EPA1993]ForsulfatetheLODwas 03mgLandLOQwas083mgLforsulfitetheLODwas05mgLandLOQwas17mgL
Water Chemistry
Watertestingwasperformed withastandardcolor-matchingDPDtestkit(TaylorTechnologiesInc SparksMaryland)TwosolutionsDPD1and2wereaddedtothewatersamplewhichdevelopeda pinkish-redcolorproportionaltothefreechlorinelevelOncethefreechlorinelevelwasobtainedtotal chlorinewasthenfoundbyaddingtheDPD3solutionCombinedchlorinewascalculatedbysubtracting freechlorinefromthetotalchlorine[TaylorTechnologiesInc2007]
References
Cambrex[2005]LimulusAmebocyteLysate(LAL)Kinetic-QCLCatalogNumber50-650U WalkersvilleMD
EPA[1993]DeterminationofinorganicanionsbyionchromatographyCincinnatiOHEnvironmental MonitoringSystemsLaboratoryOfficeofResearchandDevelopmentEnvironmentalProtectionAgency Method3000Rev21
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Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix B metHods (Continued)
INRS[2007]NitrogentrichlorideandotherchlorinatedcompoundsParisFranceInstitutnationalde rechercheetdeseacutecuriteacuteDocument007V0101
TaylorTechnologiesInc[2007]Chemistrytopics[httpwwwtaylortechnologiescom ChemistryTopicsCMASPContentID=33]DateaccessedNovember2007
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts
InevaluatingthehazardsposedbyworkplaceexposuresNIOSHinvestigatorsusebothmandatory (legallyenforceable)andrecommendedOELsforchemicalphysicalandbiologicalagentsasaguide formakingrecommendationsOELshavebeendevelopedbyFederalagenciesandsafetyandhealth organizationstopreventtheoccurrenceofadversehealtheffectsfromworkplaceexposuresGenerally OELssuggestlevelsofexposuretowhichmostworkersmaybeexposedupto10hoursperday40hours perweekforaworkinglifetimewithoutexperiencingadversehealtheffectsHowevernotallworkers willbeprotectedfromadversehealtheffectseveniftheirexposuresaremaintainedbelowtheselevelsA smallpercentagemayexperienceadversehealtheffectsbecauseofindividualsusceptibilityapre-existing medicalconditionandorahypersensitivity(allergy)Inadditionsomehazardoussubstancesmayactin combinationwithotherworkplaceexposuresthegeneralenvironmentorwithmedicationsorpersonal habitsoftheworkertoproducehealtheffectseveniftheoccupationalexposuresarecontrolledatthe levelsetbytheexposurelimitAlsosomesubstancescanbeabsorbedbydirectcontactwiththeskinand mucousmembranesinadditiontobeinginhaledwhichcontributestotheindividualrsquosoverallexposure
MostOELsareexpressedasaTWAexposureATWAreferstotheaverageexposureduringanormal8- to10-hourworkdaySomechemicalsubstancesandphysicalagentshaverecommendedSTELorceiling valueswherehealtheffectsarecausedbyexposuresoverashortperiodUnlessotherwisenotedthe STELisa15-minuteTWAexposurethatshouldnotbeexceededatanytimeduringaworkdayandthe ceilinglimitisanexposurethatshouldnotbeexceededatanytime
IntheUSOELshavebeenestablishedbyFederalagenciesprofessionalorganizationsstateand localgovernmentsandotherentitiesSomeOELsarelegallyenforceablelimitswhileothersare recommendationsTheUSDepartmentofLaborOSHAPELs(29CFR1910[generalindustry]29 CFR1926[constructionindustry]and29CFR1917[maritimeindustry])arelegallimitsenforceablein workplacescoveredundertheOccupationalSafetyandHealthActNIOSHRELsarerecommendations basedonacriticalreviewofthescientificandtechnicalinformationavailableonagivenhazard andtheadequacyofmethodstoidentifyandcontrolthehazardNIOSHRELscanbefoundinthe NIOSH Pocket Guide to Chemical Hazards[NIOSH2005]NIOSHalsorecommendsdifferenttypesof riskmanagementpractices(egengineeringcontrolssafeworkpracticesworkereducationtraining personalprotectiveequipmentandexposureandmedicalmonitoring)tominimizetheriskofexposure andadversehealtheffectsfromthesehazardsOtherOELsthatarecommonlyusedandcitedintheUS includetheTLVsrecommendedbyACGIHaprofessionalorganizationandtheWEELsrecommended bytheAmericanIndustrialHygieneAssociationanotherprofessionalorganizationTheTLVsand WEELsaredevelopedbycommitteemembersoftheseassociationsfromareviewofthepublishedpeershyreviewedliteratureTheyarenotconsensusstandardsACGIHTLVsareconsideredvoluntaryexposure guidelinesforusebyindustrialhygienistsandotherstrainedinthisdisciplineldquotoassistinthecontrolof healthhazardsrdquo[ACGIH2007]WEELshavebeenestablishedforsomechemicalsldquowhennootherlegal orauthoritativelimitsexistrdquo[AIHA2007]
OutsidetheUSOELshavebeenestablishedbyvariousagenciesandorganizationsandincludeboth legalandrecommendedlimitsSince2006theBerufsgenossenschaftlichesInstitutfuumlrArbeitsschutz (GermanInstituteforOccupationalSafetyandHealth)hasmaintainedadatabaseofinternationalOELs fromEuropeanUnionmemberstatesCanada(Queacutebec)JapanSwitzerlandandtheUS[httpwww
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
hvbgdeebiagestislimit_valuesindexhtml]Thedatabasecontainsinternationallimitsforover1250 hazardoussubstancesandisupdatedannually
EmployersshouldunderstandthatnotallhazardouschemicalshavespecificOSHAPELsandforsome agentsthelegallyenforceableandrecommendedlimitsmaynotreflectcurrenthealth-basedinformation HoweveranemployerisstillrequiredbyOSHAtoprotectitsemployeesfromhazardsevenintheabsence ofaspecificOSHAPELOSHArequiresanemployertofurnishemployeesaplaceofemploymentfree fromrecognizedhazardsthatcauseorarelikelytocausedeathorseriousphysicalharm[Occupational SafetyandHealthActof1970(PublicLaw91ndash596sec5(a)(1))]ThusNIOSHinvestigatorsencourage employerstomakeuseofotherOELswhenmakingriskassessmentandriskmanagementdecisionsto bestprotectthehealthoftheiremployeesNIOSHinvestigatorsalsoencouragetheuseofthetraditional hierarchyofcontrolsapproachtoeliminateorminimizeidentifiedworkplacehazardsThisincludesin orderofpreferencetheuseof(1)substitutionoreliminationofthehazardousagent(2)engineering controls(eglocalexhaustventilationprocessenclosuredilutionventilation)(3)administrativecontrols (eglimitingtimeofexposureemployeetrainingworkpracticechangesmedicalsurveillance)and(4) personalprotectiveequipment(egrespiratoryprotectiongloveseyeprotectionhearingprotection) Controlbandingaqualitativeriskassessmentandriskmanagementtoolisacomplementaryapproach toprotectingworkerhealththatfocusesresourcesonexposurecontrolsbydescribinghowariskneedsto bemanaged[httpwwwcdcgovnioshtopicsctrlbanding]Thisapproachcanbeappliedinsituations whereOELshavenotbeenestablishedorcanbeusedtosupplementtheOELswhenavailable
Chloramines
Chloraminesareinorganiccompoundsformedbythereactionbetweenchlorinedisinfectantsand nitrogenouscompoundssuchasammoniaaminesororganicnitrogen-containingmaterialThespecies andconcentrationsofchloraminesareinfluencedbytheconcentrationofresidualchlorineammonia(or othernitrogensources)pHandtemperatureIngeneralthelowerthepHandthegreaterthechlorineto ammoniaratiothehigherthelikelihoodofproducingtrichloramine
Soluble Chlorine Compounds
Thetermsolublechlorinedesignatesacombinationofchlorinecompoundscollectedusingthesilica gelcontainingtubeportionofthesamplerusedThesechlorinecompoundsincludemonochloramine dichloraminehypochlorousacidandhypochloriteNoOELshavebeendevelopedforsolublechlorineor foritsspecificpossibleconstituents
Monochloramineanddichloraminearelessvolatilethantrichloraminemonochloramineisreleased intotheairabout300timessloweranddichloramineaboutthreetimesslowerthantrichloramine [Holzwarth1984]TheytendtobemoreabundantinwaterthaninairHoweverhighairconcentrations ofmonochloramineanddichloraminehavebeenfoundinenvironmentswherewaterisaerosolizedIn studiesofchloramineexposuresatpoultryfacilitiesandagreensaladprocessingfacilityeyeandupper
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
respiratoryirritationsymptomswereassociatedwithsolublechlorineconcentrationsInthesescenarios solublechlorinecompoundsaregeneratedfromthemixingofchlorinatedwaterwithnitrogenousproteins producedbyanimalsandplants[Heryetal1998NIOSH2003NIOSH2006]
Trichloramine
Trichloramineornitrogentrichlorideabrownish-yellowgashasapungentchlorineodorisastrong irritantandcausesexcessivetearingoftheeyes[Barbee1983]Trichloramineisthemostvolatileand prevalentchloraminecompoundintheairaroundswimmingpools[Thickettetal2002]haslow solubilityanddecomposesrapidlyinsunlightEyeandrespiratorytractirritationappeartobetheprimary effectsofexposureCurrentlynoNIOSHorOSHAOELsexistforairtrichloramineconcentration
Endotoxin
EndotoxinarelipopolysaccharideremnantsfromtheoutercellwallofGram-negativebacteriathatare releasedwhenitdies[Hagmaretal1990Olenchock1997]Gram-negativebacteriaareubiquitousinthe environmentEndotoxinhaveawiderangeofbiologicalactivitiesinvolvinginflammatoryhemodynamic andimmunologicalresponses
Inexperimentalstudieshumanvolunteersexposedviainhalationtohighlevelsofendotoxinexperience airwayandalveolarinflammationaswellaschesttightnessfeverandmalaiseandhaveanacutereduction inlungfunctionasmeasuredbyforcedexpiratoryvolumein1second[Castellan1995Milton1999] Airborneendotoxinexposuresbetween45and400EUm3havebeenassociatedwithacuteairflow obstructionmucousmembraneirritationchesttightnesscoughshortnessofbreathfeverand wheezing[Castellanetal1987Smidetal1994Miltonetal1996]Chronichealtheffectsthathave beenassociatedwithairborneendotoxinexposuresincludechronicbronchitisbronchialhyperreactivity chronicairwaysobstructionhypersensitivitypneumonitisandemphysema[Castellan1995]Apermanent decreaseinpulmonaryfunctionalongwithrespiratorysymptomshasbeenreportedinepidemiological studies[Milton1999]
Whileacausalroleforendotoxininhumanhealtheffectshasbecomemoregenerallyacceptedinrecent yearsnodose-responserelationshiphasbeenestablishedOnereasonisthatthemostcommonlyused methodofanalyzingendotoxintheLALassayisacomparativebioassay[Milton1999]Inotherwords changesintheLALtestproceduresthemselvescanerroneouslyappearaschangesinthemeasured endotoxinactivitylevelsUntilproblemswiththeLALtestareresolvedendotoxinresultscannotbe comparedtosamplescollectedatdifferenttimesoranalyzedbydifferentlaboratoriesForthesereasons ACGIHhasproposedthatRLVsratherthanthemoreusualTLVsbeusedasareferenceforendotoxin [Milton1999]
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
RLVsrequirethatsamplesbecollectedfromanareaconsideredtorepresentbackgroundlevelsof endotoxinandbeanalyzedatthesametimeasthesamplesfromareasofinterestTheRLVisa comparisonbetweentheenvironmentinquestionandbackgroundlevelsACGIHstatesthatifhealth effectsareconsistentwithendotoxinexposureandiftheendotoxinexposuresexceed10timesthe simultaneouslydeterminedbackgroundlevelsthentheRLVactionlevelhasbeenexceededand actionshouldbetakentoreduceexposure[Milton1999]TheproposedmaximumRLVrisesto30 timesthebackgroundlevelinanenvironmentwherenosymptomsarereported[Milton1999]When exposuresexceedtheRLVactionlevelormaximumRLVremedialactionstocontrolendotoxinlevelsare recommendedItisimportanttonotethatthenatureoftherelationshipbetweentheRLVandhealth effectshasnotbeenelucidatedatthistime
Legionella
IllnessesrelatedtoL pneumophilabacteriaaffectanestimated8000to18000peopleannuallyinthe UnitedStates[CDC2005]Atleast46speciesand70serogroupshavebeenidentifiedintheLegionella genusL pneumophilaisaubiquitousaquaticorganismthatthrivesinwarmenvironments(32degCndash45degC) andhasbeenassociatedwithover90ofthelegionellosiscasesintheUnitedStates[CDC2005] ThesourceofLegionellaisnotidentifiedinmostsporadiccasesoflegionellosis(casesoccurringinnonshyoutbreaksettings)Morecasesareusuallyidentifiedinthesummerandearlyfallbuttheycanoccurany timeofyear
EnvironmentalsamplingforLegionellacanbeusefulinafewveryspecificcircumstances(suchasin outbreakinvestigations)particularlywhenLegionellaisolatesareavailablefromoneormorecase-patients andcanthereforebetyped(specificallyidentified)andcomparedwithenvironmentalisolates[CDC 2001]OtherthaninthesespecificcircumstancesenvironmentalsamplingforLegionellaisgenerallynot recommendedbecausetheorganismsarefoundcommonlyintheenvironmentandhavebeenisolated fromnearlyeverynaturallocationwheretheyhavebeensoughtReservoirsforLegionella bacteriaare primarilyaqueous(involvingwater)andincludepotablewatersystemsair-conditioningcoolingtowers evaporativecondensersandhot-watersystems[Beninetal2002Fields2002OSHA2005aSabriaand Yu2008]
LegionellosiscanpresentintwoformsLegionnairesrsquodiseasetypicallyincludespneumoniaandcanaffect numerousorgansofthebodyillnessusuallyoccurswithin2to14daysafterexposuretothebacteria [CDC2005]TreatmentofLegionnairesrsquodiseaserequiresantibioticsPontiacfevertheotherclinicalform oflegionellosispresentsasaflu-likeillnessthatoccurswithin48to72hoursafterexposuretothebacteria [CDC2005]Pontiacfeveristreatedwithsymptom-basedtreatmentratherthanantibioticsComplete recoveryfromPontiacfevergenerallytakesplacewithinafewdaysEpidemiologicalevidenceindicatesthat theprimarymodeoftransmissionofLegionellaisviatheairborneroutefromaerosol-producingdevices [AWT2003OSHA2005b]Person-to-persontransmissionhasnotbeenreported
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
Sulfites and Sulfates
Nostandardorguidelinesexistforacceptablesulfiteandsulfateconcentrationsinswimmingpoolwater WatersamplesweretakenattherequestofGWLmanagement
Mycobacteria
Mycobacteriaarerod-shapedbacteriathathavecellwallswithahighlipid(fat)contentTheyarefound inagreatvarietyofnaturalandhuman-influencedaquaticenvironmentsincludinginandaround swimmingpoolshottubsandspastreateddrinkingwaterandaerosolsTheyarereadilyaerosolized fromaqueoussuspensionAerosolizationiscausedbythegenerationofairbornedropletsfrombubbles burstingatthewatersurfaceRecentlyreportshavelinkedexposuretovariousspeciesofmycobacteria inpoolsandnaturalwaterstothedevelopmentofvariousrespiratoryillnessesTheseincludebronchitis hypersensitivitypneumonitisgranulomatouspneumonitisandallergicalveolitis[Schaferetal2003]For exampleMycobacterium avium inspawaterhasbeenlinkedtohypersensitivitypneumonitisandpossibly pneumonia[Embiletal1997]Symptomswereflu-likeandincludedcoughfeverchillsmalaiseand headachesTheillnessesfollowedtheinhalationofheavilycontaminatedaerosolsgeneratedbythespa
Duetothehighlipidcontentoftheircellwallmycobacteriaareveryresistanttothedisinfectantsused inwatertreatmentincludingchlorineandozone[Engelbrechtetal1977Falkinham2003]Therefore itisessentialtomaintainrecommendeddisinfectionresidualsinhottubsspasandpoolsatalltimes toreducetherisksofacquiringswimmingpoolgranulomaorrespiratoryillnesscausedbymycobacteria Thoroughcleaningofsurfacesandmaterialsaroundpoolsandspaswheretheorganismmaypersistisalso necessary[Collinsetal1984]
References
ACGIH[2007]2007TLVsandBEIsregthresholdlimitvaluesforchemicalsubstancesandphysicalagents CincinnatiOHAmericanConferenceofGovernmentalIndustrialHygienists
AIHA[2007]2007Emergencyresponseplanningguidelines(ERPG)ampworkplaceenvironmental exposurelevels(WEEL)handbookFairfaxVAAmericanIndustrialHygieneAssociation
AWT[2003]Legionella2003AssociationofWaterTechnologies(AWT)McLeanVA[httpwwwawr orgIndustryResourcesLegionella03pdf]DateaccessedNovember202008
BarbeeSJThackaraJWRinehartWE[1983]AcuteinhalationtoxicologyofnitrogentrichlorideAmInd HygAssocJ44(2)145ndash146
Page Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
BeninALBensonRFBesserRE[2002]TrendsinLegionnairesrsquodisease1980-1998decliningmortality andnewpatternsofdiagnosisClinInfectDis35(9)1039ndash1046
CastellanRM[1995]RespiratoryhealtheffectsofinhaledendotoxinsbyssinosisandbeyondIn McDuffieHDosmanJSemchukKOlenchockSedsAgriculturalHealthandSafety-Workplace EnvironmentSustainabilityBocaRatonFLCRCPresspp97ndash100
CastellanROlenchockSKinsleyKHankinsonJ[1987]Inhaledendotoxinanddecreasedspirometric valuesanexposureresponserelationforcottondustNEnglJMed317(10)605ndash610
CDC[2005]LegionellosisLegionnairesrsquodisease(LD)andPontiacfeverCentersforDiseaseControl andPreventionAtlantaGA[httpwwwcdcgovncidoddbmddiseaseinfolegionellosisghtml]Date accessedSeptember252007
CDC[2001]OutbreakofLegionnairesrsquodiseaseamongautomotiveplantworkersmdashOhio2001MMWR 50357-359[httpwwwcdcgovmmwrpreviewmmwrhtmlmm5018a1htmlDateaccessedSeptember 252007
CFRCodeofFederalRegulationsWashingtonDCUSGovernmentPrintingOfficeOfficeofthe FederalRegister
CollinsCHGrangeJMYatesMD[1984]MicrobiologicalhazardsInGuidelinesforsafe recreational-waterenvironments-volume2swimmingpoolsspasandsimilarrecreationalwater environmentsAugust2000reved[httpwwwwhointdocstorewater_sanitation_health Recreational_waterhtmVolume2recreatIIs-chap3htm]DateaccessedSeptember252007
EmbilJWarrenPYakrusMCorneSForrestDHershfieldE[1997]Pulmonaryillnessassociatedwith exposuretoMycobacterium-avium complexinhottubwaterChest111(3)534ndash536
EngelbrechtRSSeverninBFMassarikMTFarooSLeeSHHaasCNLalchandaniA[1977]New microbialindicatorsofdisinfectionefficiencyWashingtonDCUnitedStatesEnvironmentalProtection AgencyTechnologicalSeriesNoEPA6002-77-052
FalkinhamJO[2003]MycobacterialaerosolsandrespiratorydiseaseEmergInfecDis9(7)763ndash767
FieldsBSBensonRFBesserRE[2002]LegionellaandLegionnairesrsquodisease25yearsofinvestigation ClinMicrobiolRev15(3)506ndash526
HagmarLSchuumltzAHallbergTSjoumlholmA[1990]Healtheffectsofexposuretoendotoxinsandorganic dustinpoultryslaughter-houseworkersIntArchOccupEnvironHealth62159ndash164
Health Hazard Evaluation Report 2007-0163-3062 Page
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
HeryMGerberJMHechtGSubraIPossozCAubertSDieudonneMAndreJC[1998]Exposureto chloraminesinagreensaladprocessingplantAnnOccupHyg42(7)437ndash451
HolzwarthGBalmerRGSoniL[1984]ThefateofchlorineandchloraminesincoolingtowersWater Res18(11)1421ndash1427
MiltonDK[1999]Endotoxinandotherbacterialcell-wallcomponentsInMacherJed BioaerosolsassessmentandcontrolCincinnatiOHAmericanConferenceofGovernmental IndustrialHygienistspp23ndash1to23ndash14
MiltonDKWypijDKriebelDWaltersMDHammondSKEvansJS[1996]Endotoxin exposure-responseinafiberglassmanufacturingplantAmJIndMed293ndash13
NIOSH[2003]HazardevaluationandtechnicalassistancereportBil-MarFoodsIncStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2002-0257-2916
NIOSH[2005]NIOSHpocketguidetochemicalhazardsCincinnatiOHUSDepartmentofHealth andHumanServicesCentersforDiseaseControlandPreventionNationalInstituteforOccupational SafetyandHealthDHHS(NIOSH)PublicationNo2005-149[httpwwwcdcgovnioshnpg]Date accessedNovember2007
NIOSH[2006]HazardevaluationandtechnicalassistancereportSaraLeeFoodsStormLakeIA CincinnatiOHUSDepartmentofHealthandHumanServicesPublicHealthServiceCentersfor DiseaseControlandPreventionNationalInstituteforOccupationalSafetyandHealthNIOSHHETA ReportNo2006-0153-3022
OlenchockS[1997]AirborneendotoxinInHurstCJKnudsenGRMcInerneyMJStetzenbach LDWalterMVedsManualofenvironmentalmicrobiologyWashingtonDCAmericanSocietyfor MicrobiologyPresspp661ndash665
OSHA[2005a]SafetyandhealthtopicsLegionnairesrsquodiseaseOccupationalSafetyampHealth Administration[httpwwwoshagovSLTClegionnairesdisease]DateaccessedNovember202007
OSHA[2005b]OSHATechnicalManualSectionIIIChapter7Legionnairesrsquodisease[httpwwwosha govdtsostaotmotm_iiiotm_iii_7html]DateaccessedNovember202007
SabriaMYuVL[2008]LegionellainfectionInFauciASKasperDLLongoDLBraunwaldEHauser SLJamesomJLLoscalzoJetsHarrisonrsquosPrinciplesofInternalMedicine17theditionpp929ndash933 McGraw-HillNewYork
Page 0 Health Hazard Evaluation Report 2007-0163-3062
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Appendix C oCCupAtionAl exposuRe limits And HeAltH effeCts (Continued)
SchaferMPMartinezKFMatthewsES[2003]Rapiddetectionanddeterminationoftheaerodynamic sizerangeofairbornemycobacteriaassociatedwithwhirlpoolsApplOccupEnvironHyg18(1)14ndash50
SmidTHeederickDHoubaRQuangerPH[1994]Dust-andendotoxin-relatedacutelungfunction changesandwork-relatedsymptomsinworkersintheanimalfeedindustryAmJIndMed25(6)877ndash888
ThickettKMMcCoachJSGerberJMSadhraSBurgePS[2002]Occupationalasthmacausedby chloraminesinindoorswimming-poolairEurRespirJ19827ndash832
Health Hazard Evaluation Report 2007-0163-3062 Page
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
ACknowledgements And
AvAilABility of RepoRt
TheHazardEvaluationsandTechnicalAssistanceBranch (HETAB)oftheNationalInstituteforOccupationalSafetyand Health(NIOSH)conductsfieldinvestigationsofpossiblehealth hazardsintheworkplaceTheseinvestigationsareconducted undertheauthorityofSection20(a)(6)oftheOSHAActof1970 29USC669(a)(6)whichauthorizestheSecretaryofHealthand HumanServicesfollowingawrittenrequestfromanyemployers orauthorizedrepresentativeofemployeestodeterminewhether anysubstancenormallyfoundintheplaceofemploymenthas potentiallytoxiceffectsinsuchconcentrationsasusedorfound
HETABalsoprovidesuponrequesttechnicalandconsultative assistancetofederalstateandlocalagencieslaborindustryand othergroupsorindividualstocontroloccupationalhealthhazards andtopreventrelatedtraumaanddiseaseMentionofcompany namesorproductsdoesnotconstituteendorsementbyNIOSH
ThisreportwaspreparedbyLiliaChenBichDangandCharles MuellerofHETABDivisionofSurveillanceHazardEvaluations andFieldStudiesKevinHDunnandDanielAlmaguerofthe EngineeringandPhysicalHazardsBranchDivisionofApplied ResearchandTechnology(DART)andJenniferLErnstof ChemicalExposureMonitoringBranchDARTwiththehelp ofCharlesSOttofromtheNationalCenterforEnvironmental HealthIndustrialhygienefieldassistancewasprovidedby ChandranAchutanNancyBurtonGregBurrChadDowell SrinivasDurgamLindaEwersAndreaMarkeyJessicaRamsey ManuelRodriguezandAaronSussellMedicalfieldassistance wasprovidedbyFangGongMargaretRiggsSaraLuckhaupt andAngelaWarrenAnalyticalsupportwasprovidedbyTamara WiseAerotechPampKandMicrobiologySpecialistsIncDesktop publishingwasperformedbyRobinSmithEditorialassistancewas providedbyEllenGallowayHealthcommunicationassistancewas providedbyStefanieEvansTheenvironmentalhealthevaluation wasperformedbyrepresentativesfromtheOhioDepartmentof HealthandWarrenCountyCombinedHealthDistrict
Copiesofthisreporthavebeensenttoemployeeandmanagement representativesatGreatWolfLodgetheWarrenCounty CombinedHealthDistrictandtheOSHARegionalOfficeThis reportisnotcopyrightedandmaybefreelyreproducedThereport
Page Health Hazard Evaluation Report 2007-0163-3062
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
ACknowledgements And
AvAilABility of RepoRt
(Continued) maybeviewedandprintedfromthefollowinginternetaddress httpwwwcdcgovnioshhheCopiesmaybepurchasedfrom theNationalTechnicalInformationServiceat5825PortRoyal RoadSpringfieldVirginia22161
Health Hazard Evaluation Report 2007-0163-3062 Page
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe
Below is a recommended citation for this report NIOSH [2008] Health Hazard Evaluation Report Investigation of employee symptoms at an indoor waterpark Mason OH Cincinnati OH US Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health NIOSH HETA No 2007-0163-3062
To receive NIOSH documents or information about occupational safety and health topics contact NIOSH at 1-800-CDC-INFO (1-800-232-4636) TTY 1-888-232-6348 E-mail cdcinfocdcgov
or visit the NIOSH web site at wwwcdcgovniosh
For a monthly update on news at NIOSH subscribe to NIOSH eNews by visiting wwwcdcgovniosheNews
Delivering on the Nationrsquos promise Safety and health at work for all people through research and prevention
National Institute for Occupational Safety and Health
- Investigation of Employee Symptoms at an Indoor Waterpark
- Employer Posting Regulation
- Table of Contents13
- Abbreviations13
- Highlights of the NIOSH Health Hazard Evaluation13
- Summary13
- Keywords13
- Introduction13
- Assessment13
- Results13
- Discussion13
- Conclusions13
- References13
- Appendix A Tables13
- Appendix B Methods13
- Appendix C Occupational Exposure Limits and Health Effects13
- Acknowledgements and Availability of Report13
- Recommended citation for this report and additional contact information13
-
- NIOSH Disclaimer statement This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific facility evaluated and may not be universally applicable Any recommendations made are not to be considered as final statements of NIOSH policy or of any agency or individual involved Additional HHE reports are available at httpwwwcdcgovnioshhhe