Does outdoor or indoor air pollution cause more respiratory disease Evidence from the Central Europe

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Does outdoor or indoor air pollution cause more
respiratory disease? Evidence from the Central
European Study on Air Pollution and Respiratory
Health (CESAR Study).
Tony Fletcher, London School of Hygiene and
Tropical Medicine, London. UKBrunekreef B,
Houthuijs D, Fabianova E, Lebret E, Leonardi G,
Gurzau E, Nikiforov B, Rudnai P, Volf J, Zejda J.

Central European Study of Air Pollution and
Respiratory Health
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CESAR National Research Teams
Bulgaria National Centre of Hygiene, Bojidar
Nikiforov Czech Republic Regional Institute of
Hygiene Ostrava, Jaroslav Volf Hungary National
Institute of Public Health, Alan Pintér and Peter
Rudnai Poland Institute of Occupational
Medicine and Environmental Health, Jan Zejda
Romania Environmental Health Center, Eugen
Gurzau Slovakia Regional Specialized Institute
of Public Health Banska Bystrica, Eleonorá
Fabiánová United Kingdom LSHTM, Tony Fletcher,
Giovanni Leonardi and Sam Pattenden The
Netherlands WAU, Bert Brunekreef and Gerard
Hoek The Netherlands RIVM, Erik Lebret, Annelike
Dusseldorp and Danny Houthuijs
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CESAR - AIMS
Establish comparable base-line data
on childrens respiratory health air
pollution, including PM10 and PM2.5 environment
and health risk perceptions Investigate effects
on respiratory health of air pollution indoor
and other risks factors Capacity
building (epidemiological) research
methods introduction of QA/QC methods
Central European Study of Air Pollution and
Respiratory Health
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European Funding for CESAR
1994-1997 EC - PHARE Programme 1999-2000 EC -
INCO Copernicus
Central European Study of Air Pollution and
Respiratory Health
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Study characteristics

• Cross-sectional study among children aged 7 - 11
  year in 6 countries
• Four (five) study areas per country 25 study
  areas
• Selection of study areas within countries based
  on differences in air pollution levels and in
  dominant local sources
• Participation of about 1,000 children per study
  area
• Current concentration of PM10 and PM2.5 measured
  in all study areas
• Assessment of respiratory health endpoints and
  potential confounders at individual level

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CESAR Study areas
Central European Study of Air Pollution and
Respiratory Health
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Methods

• 24 hour sampling, once every six days, during Nov
  1995 - Oct 1996
• background sampling site
• Harvard impactors with cut-off points at 2.5 and
  10 µm
• preparation and analysis in one central
  laboratory per country
• Questionnaire respiratory symptoms and
  conditions based on items from WHO, ISAAC and
  ATS in children 7 - 11 years old
• Base-line pulmonary function test (FVC and FEV1)
  in children age 9 - 11
• Information on risk factors and potential
  confounders collected by questionnaire

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Questionnaire based health endpoints

• Cough on most days for at least 3 months
  consecutively in the last autumn-winter season
• Any cough symptom over life time (combination)
• Any wheeze symptom in the last 12 months
  (combination)
• Any wheeze symptom over lifetime (combination)
• Bronchitis doctor diagnosed, ever
• Bronchitis in last 12 months
• Asthma doctor diagnosed, ever
• Asthma attacks in last 12 months
• Medication use for a breathing trouble in last 12
  months

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Risk factors in model

• Age, sex
• country
• current of smokers in the home
• use of gas range or oven for heating in winter
• use of unvented gas, oil or kerosene heater
• ever moisture stains or mould in the home over
  lifetime of child

• Furniture with chipboard
• Reported frequency of traffic passing the house
• Consumption of fruit, vegetables and fish
• education of the mother
• occupation of the father
• Parental history of wheeze, asthma, inhalant
  allergy, eczema or hay fever

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Statistical analyses

• Assessment of current annual average
  concentrations for PM10, PM2.5 and coarse
  fraction
• Two stage regression of area-specific
  means/logits after adjustment for potential
  individual confounders
• Random effects models at taking into account
  within country correlations for estimating
  pollution effect
• Attributable fraction calculation of
  attributable fractions from logistic regression
  models

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Numbers in study

• total population 20271
• 3470 (1 Country) dropped for lack of PM data
• 2899 dropped for missing values in one or more
  variables in the models
• subjects used in these analyses 13902

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CESAR - 25 Study areas
Bulgaria Sofia suburb Thermal power
station Sofia centre Traffic Vratza Chemicals, As
senovgrad Metallurgical Czech Republic Ostrava
centre Local heating, traffic Ostrava
-Vitkovice Iron works, power, coke Ostrava -
Poruba No local sources Ostrava - Radvanice Iron
works, coke oven Hungary Cegled No local
sources Dorog Local heat., power plant, pharmac.
Eger Local heat., intense traffic, agric.
Tata Local heating, moderate traffic Tatabanya Lo
cal heating, coal/ oil power
Poland Kedzierzyn - Kozle Chemical
plant Kielce Clean, recreational
area Pszczyna Clean area Swietochlowice Metallurg
., coal, chemical Romania Bucharest Traffic,
local heating Ploiesti Petrochemical,
chemicals Baja Mare Metallurgical industry Tirgu
Mures Chemical industry Slovakia Banska
Bystrica suburb No local sources Banska Bystrica
centre Traffic, cement plant Zilina
Chemical, paper factories Bratislava
Traffic, local heating
Central European Study of Air Pollution and
Respiratory Health
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Cough and PM2.5 by study area

60
P
P
P
C
C
C
C
P
40
S

any cough symptoms ever ()
S
S
B
B
B
B
S
20
H
H
H
H
H
0
30
40
50
60
70
PM2.5-concentration (µg/m3)

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Wheeze and PM2.5 by study area

50
B
B
B
B
40

any wheeze symptoms ever ()
30
C
C
C
P
H
P
H
H
C
P
H
P
H
20
S
S
S
S
10
30
40
50
60
70
PM2.5-concentration (µg/m3)

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Example of some risk factors for Wheeze
Prevalence, Odds ratios and Attributable fractions
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Conclusions

• attributable fractions are a helpful indicator
  for interpreting these results and could be used
  more widely
• parental history of respiratory illness and
  indicators of socioeconomic status are important
  contributors to symptom prevalence
• air pollution is more important for some symptoms
  than indoor combustion sources, ETS or dampness
• the presence of chipboard furniture is very
  prevalent and appears to be associated with
  substantial attributable fractions for some
  symptoms

Central European Study of Air Pollution and
Respiratory Health