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Shen P, Hu D, Shen M, Du T, Zhao L, Han M, Song R, Guo R, Lu X, Liu S, Shen X. Association of mixed polycyclic aromatic hydrocarbons exposure with hearing loss and the mediating role of blood cell markers of inflammation in U.S. adults. Front Public Health 2024; 12:1410601. [PMID: 39664550 PMCID: PMC11631931 DOI: 10.3389/fpubh.2024.1410601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 11/11/2024] [Indexed: 12/13/2024] Open
Abstract
Introduction Studies on the effects of polycyclic aromatic hydrocarbons (PAHs) on hearing loss (HL) are limited and often focus on individual PAH compounds. The present study aimed to explore the individual and combined effects of PAH exposure on hearing loss, with a focus on the mediating role of inflammatory blood cell markers. Methods This cross-sectional study included 1,409 participants from 3 cycles of the National Health and Nutrition Examination Survey (2001-2002, 2003-2004, and 2011-2012). Seven monohydroxylated PAH metabolites (OH-PAHs) in the urine were measured. Multivariable logistic regression, weighted quantile sum (WQS) regression, and Bayesian kernel machine regression (BKMR) were applied to assess both the individual and combined effects of OH-PAHs on hearing loss. Moreover, mediation analysis was employed to examine the mediating role of inflammatory blood cell markers in these associations. Results Among the 1,409 participants, 59.1% had hearing loss. The WQS model revealed a positive association between PAH mixtures and HL (OR: 1.290; 95% CI: 1.042, 1.597), LFHL (OR: 1.363; 95% CI: 1.130, 1.644), and HFHL (OR: 1.299; 95% CI: 1.022, 1.626). Additionally, the WQS model identified hydroxynaphthalene (1-OHNAP) primarily contributed to HL and LFHL, while 2-hydroxyfluorene (2-OHFLU) was the primary contributor to HFHL. BKMR analysis demonstrated positive associations between PAH mixtures and all three types of hearing loss. Mediation analysis revealed that the association between OH-PAHs and LFHL was mediated by neutrophil (NEU) and basophil (BAS) counts. Discussion These results confirmed that exposure to PAH mixtures was positively associated with the odds of hearing loss and that inflammatory blood cell markers mediated this association.
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Affiliation(s)
- Peixuan Shen
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
| | - Dan Hu
- Licang District Center for Disease Control and Prevention, Qingdao, China
| | - Meiyue Shen
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
| | - Tingwei Du
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
| | - Longzhu Zhao
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
| | - Miaomiao Han
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
| | - Ruihan Song
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
| | - Rongrong Guo
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
| | - Xiaochuan Lu
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
| | - Shengnan Liu
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
| | - Xiaoli Shen
- Department of Epidemiology and Health Statistics, School of Public Health, Qingdao University, Qingdao, China
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Fang P, Zhang JJ, Lu ZQ, Li S, Xia DL, Xu Q, Wu XH, Sun GY, You QH, Fu L. Effects of single and combined urinary polycyclic aromatic hydrocarbon effects on lung function in the U.S. adult population. BMC Public Health 2024; 24:2778. [PMID: 39394095 PMCID: PMC11468208 DOI: 10.1186/s12889-024-20267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 10/03/2024] [Indexed: 10/13/2024] Open
Abstract
BACKGROUND The impact of polycyclic aromatic hydrocarbons (PAHs) on lung function has garnered attention, but studies mostly focus on individual effect. This study investigates urinary PAH metabolites as biomarkers of exposure and assesses the relationships between single and combined exposures to nine urinary PAH metabolites and lung function in adults. METHODS Data from 4040 adults in the 2007-2012 National Health and Nutrition Examination Survey (NHANES) were analyzed. Weighted generalized linear models estimated the effects of individual PAH metabolites on lung function. Additionally, weighted quantile sum (WQS) regression, quantile g-computation (qgcomp), and Bayesian kernel machine regression (BKMR) were employed to evaluate the combined impacts of multiple PAH metabolites. RESULTS Analyses of individual PAH metabolites revealed negative associations with lung function, excluding forced vital capacity (FVC). The WQS, qgcomp, and BKMR models consistently showed that exposure to multiple PAH metabolites was associated with lung function decrease. WQS indicated that 2-hydroxynaphthalene (2-NAP) was the largest contributor to the reductions in forced expiratory volume in 1 s (FEV1), FVC, peak expiratory flow (PEF), and forced expiratory flow from 25 to 75% of FVC (PEF25-75%). Additionally, 1-hydroxypyrene (1-PYR) was the primary PAH metabolite contributing to the decreases in FEV1/FVC and fractional exhaled nitric oxide (FeNO). The combined effect of urinary PAH metabolites did not affect FVC in the current smokers or FeNO in nonsmokers, but decreased FEV1/FVC in current smokers. CONCLUSION This study strengthens the negative relationships between multiple PAH metabolites exposure and lung function in adults. Given the limitations of this study, including the lack of knowledge of other exposure pathways and the uncertainty of urinary metabolites, further research is necessary to explore the mechanisms underlying these associations and to address the limitations in exposure assessment.
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Affiliation(s)
- Pu Fang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Jin-Jin Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Zong-Qing Lu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Shuai Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Dun-Lin Xia
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Qin Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Xiang-Hui Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China
| | - Geng-Yun Sun
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China.
| | - Qing-Hai You
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, China.
| | - Lin Fu
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230032, China.
- Center for Big Data and Population Health of IHM, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, China.
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Wu L, Lu X, Zhang S, Zhong Y, Gao H, Tao FB, Wu X. Co-exposure effects of urinary polycyclic aromatic hydrocarbons and metals on lung function: mediating role of systematic inflammation. BMC Pulm Med 2024; 24:386. [PMID: 39128985 PMCID: PMC11316979 DOI: 10.1186/s12890-024-03173-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/15/2024] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND Polycyclic aromatic hydrocarbons (PAHs) and metals were associated with decreased lung function, but co-exposure effects and underlying mechanism remained unknown. METHODS Among 1,123 adults from National Health and Nutrition Examination Survey 2011-2012, 10 urinary PAHs, 11 urinary metals, and peripheral white blood cell (WBC) count were determined, and 5 lung function indices were measured. Least absolute shrinkage and selection operator, Bayesian kernel machine regression, and quantile-based g-computation were used to estimate co-exposure effects on lung function. Mediation analysis was used to explore mediating role of WBC. RESULTS These models demonstrated that PAHs and metals were significantly associated with lung function impairment. Bayesian kernel machine regression models showed that comparing to all chemicals fixed at median level, forced expiratory volume in 1 s (FEV1)/forced vital capacity, peak expiratory flow, and forced expiratory flow between 25 and 75% decreased by 1.31% (95% CI: 0.72%, 1.91%), 231.62 (43.45, 419.78) mL/s, and 131.64 (37.54, 225.74) mL/s respectively, when all chemicals were at 75th percentile. In the quantile-based g-computation, each quartile increase in mixture was associated with 104.35 (95% CI: 40.67, 168.02) mL, 1.16% (2.11%, 22.40%), 294.90 (78.37, 511.43) mL/s, 168.44 (41.66, 295.22) mL/s decrease in the FEV1, FEV1/forced vital capacity, peak expiratory flow, and forced expiratory flow between 25% and 75%, respectively. 2-Hydroxyphenanthrene, 3-Hydroxyfluorene, and cadmium were leading contributors to the above associations. WBC mediated 8.22%-23.90% of association between PAHs and lung function. CONCLUSIONS Co-exposure of PAHs and metals impairs lung function, and WBC could partially mediate this relationship. Our findings elucidate co-exposure effects of environmental mixtures on respiratory health and underlying mechanisms, suggesting that focusing on highly prioritized toxicants would effectively attenuate adverse effects.
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Affiliation(s)
- Lihong Wu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
- Key Laboratory of Population Health Across Life Cycle (Anhui Medical University), Ministry of Education of the People's Republic of China, No 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Provincial Key Laboratory of Environment and Population Health Across the Life Course, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Xue Lu
- Department of Toxicology, Anhui Medical University, Anhui, China
| | - Siying Zhang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Yumei Zhong
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Hui Gao
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, No 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Fang-Biao Tao
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
- Key Laboratory of Population Health Across Life Cycle (Anhui Medical University), Ministry of Education of the People's Republic of China, No 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Provincial Key Laboratory of Environment and Population Health Across the Life Course, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Xiulong Wu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China.
- Key Laboratory of Population Health Across Life Cycle (Anhui Medical University), Ministry of Education of the People's Republic of China, No 81 Meishan Road, Hefei, 230032, Anhui, China.
- Anhui Provincial Key Laboratory of Environment and Population Health Across the Life Course, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China.
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Zhang H, Liu R, Yang L, Cheng H, Wang S, Zhang B, Shao J, Ma S, Norbäck D, Zhang X, An T. Exposure to polycyclic aromatic hydrocarbons (PAHs) in outdoor air and respiratory health, inflammation and oxidative stress biomarkers: A panel study in healthy young adults. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 899:165582. [PMID: 37467979 DOI: 10.1016/j.scitotenv.2023.165582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/08/2023] [Accepted: 07/15/2023] [Indexed: 07/21/2023]
Abstract
Exposure to polycyclic aromatic hydrocarbons (PAHs) can be associated with different types of health effects. However, the systemic changes of health effects between fluctuations of PAHs exposure have not been established. In this study, urinary hydroxylated PAHs (OH-PAHs) and 12 biomarkers were determined among 36 students from the urban to the suburb in Taiyuan in 2019. The concentration of Σ12OH-PAHs in urban areas (28.2 and 21.4 μg/g Cr) was significantly higher than that in suburban area (16.8 μg/g Cr). The regression showed that hydroxy-phenanthrene (OH-Phe, 1/2/3/4/9-OH-Phe) was significantly positively correlated with lung function (PEF25 and PEF50), 8-hydroxydeoxyguanosine (8-OHdG), interleukin-8 (IL-8), and fractional exhaled nitric oxide (FeNO). Moreover, there were negative associations of 2-hydroxyfluorene (2-OH-Flu) with FVC and FEV1. 1 unit increase of 1-hydroxypyrene (1-OH-Pyr) was negatively associated with 18.8% FVC, 17.3% FEV1, and 26.4% PEF25 in the suburban location, respectively. During urban2, each unit change of 2-OH-Flu was associated with 10.9% FVC and 10.5% FEV1 decrease, which were higher than those in suburban location. 8-OHdG decreased by 32.0% with each unit increase in 3-hydroxyfluorene (3-OH-Flu) during urban2 (p < 0.05), while 1.9% in the suburban location. During the suburban period, the increase in OH-Phe was correlated with the decrease in malondialdehyde (MDA). The respiratory damage caused by PAHs in the urban disappeared after backing to the urban from the suburban area. Notably, despite the total significant liner mixed regression association of FeNO with multiple OH-PAHs, the association of FeNO with OH-PAHs was not significant during different periods except for 2-OH-Flu. Our findings suggested that short-term exposure to different concentrations of PAHs might cause changes in health effects and called for further research to investigate possible alterations between health effects and PAH exposure.
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Affiliation(s)
- Huilin Zhang
- Institute of Environmental Science, Shanxi University, Taiyuan 030006, China
| | - Ranran Liu
- Shandong Academy of Occupational Health and Occupational Medicine, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan 250062, China; Guangzhou Key Laboratory of Environmental Catalysis and Pollution Control, Guangdong-Hong Kong-Macao Joint Laboratory for Contaminants Exposure and Health, School of Environmental Science and Engineering, Institute of Environmental Health and Pollution Control, Guangdong University of Technology, Guangzhou 510006, China
| | - Liu Yang
- Institute of Environmental Science, Shanxi University, Taiyuan 030006, China
| | - Hong Cheng
- Institute of Environmental Science, Shanxi University, Taiyuan 030006, China
| | - Shengchun Wang
- Institute of Environmental Science, Shanxi University, Taiyuan 030006, China
| | - Bin Zhang
- Institute of Environmental Science, Shanxi University, Taiyuan 030006, China
| | - Jiyuan Shao
- Institute of Environmental Science, Shanxi University, Taiyuan 030006, China
| | - Shengtao Ma
- Guangzhou Key Laboratory of Environmental Catalysis and Pollution Control, Guangdong-Hong Kong-Macao Joint Laboratory for Contaminants Exposure and Health, School of Environmental Science and Engineering, Institute of Environmental Health and Pollution Control, Guangdong University of Technology, Guangzhou 510006, China
| | - Dan Norbäck
- Department of Medical Sciences, Uppsala University, Uppsala SE-751, Sweden
| | - Xin Zhang
- Institute of Environmental Science, Shanxi University, Taiyuan 030006, China.
| | - Taicheng An
- Guangzhou Key Laboratory of Environmental Catalysis and Pollution Control, Guangdong-Hong Kong-Macao Joint Laboratory for Contaminants Exposure and Health, School of Environmental Science and Engineering, Institute of Environmental Health and Pollution Control, Guangdong University of Technology, Guangzhou 510006, China
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Werthmann D, van Wendel de Joode B, Cuffney MT, Reich BJ, Soto-Martinez ME, Corrales-Vargas A, Palomo-Cordero L, Peñaloza-Castañeda J, Hoppin JA. A cross-sectional analysis of medical conditions and environmental factors associated with fractional exhaled nitric oxide (FeNO) in women and children from the ISA birth cohort, Costa Rica. ENVIRONMENTAL RESEARCH 2023; 233:116449. [PMID: 37356534 PMCID: PMC10529647 DOI: 10.1016/j.envres.2023.116449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a marker of airway inflammation. Elevated FeNO has been associated with environmental exposures, however, studies from tropical countries are limited. Using data from the Infants' Environmental Health Study (ISA) birth cohort, we evaluated medical conditions and environmental exposures' association with elevated FeNO. METHODS We performed a cross-sectional analysis of 277 women and 293 8-year old children who participated in the 8-year post-partum visit in 2019. We measured FeNO and collected information on medical conditions and environmental exposures including smoke from waste burning, work in banana plantations, and home pesticide use. We defined elevated FeNO as >25 ppb for women and >20 ppb for children. To evaluate factors associated with elevated FeNO, we used logistic regression models adjusted for obesity in women and unadjusted in children. RESULTS Overall elevated FeNO was common (20% of women, 13% of children). Rhinitis diagnosis was significantly associated with elevated FeNO in both women (odds ratio (OR): 3.67 95% Confidence Interval (CI): 1.81,7.35) and children (OR: 8.18 95%CI: 3.15, 21.22); wheeze was associated with elevated FeNO in women (OR: 4.50 95% CI: 2.25, 8.99). Environmental exposures were associated with elevated FeNO, but not significantly. Waste burning was associated with elevated FeNO in both women (OR: 1.58 95%CI 0.68, 4.15) and children (OR: 2.49 95%CI:0.82, 10.79). Para-occupational pesticide exposures were associated with elevated FeNO in women and children. For women, having a partner working in agriculture was associated with elevated FeNO (OR: 1.61 95%CI:0.77, 3.58) and for children, maternal work in agriculture was associated with elevated FeNO. (OR 2.08 95%CI 0.86, 4.67) CONCLUSION: Rhinitis and wheeze were associated with elevated FeNO in this rural, agricultural population. Smoke from waste burning as well as para-occupational pesticide exposure may contribute to elevated FeNO in rural communities.
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Affiliation(s)
- Derek Werthmann
- Department of Biological Sciences, NC State University, Raleigh, NC, USA; Center for Human Health and the Environment, NC State University, Raleigh, NC, USA
| | - Berna van Wendel de Joode
- Infants Environmental Health Program (ISA) Central American Institute for Studies on Toxic Substances (IRET), Universidad Nacional, Heredia, Costa Rica
| | - Michael T Cuffney
- Department of Biological Sciences, NC State University, Raleigh, NC, USA
| | - Brian J Reich
- Center for Human Health and the Environment, NC State University, Raleigh, NC, USA; Department of Statistics, NC State University, Raleigh, NC, USA
| | | | - Andrea Corrales-Vargas
- Infants Environmental Health Program (ISA) Central American Institute for Studies on Toxic Substances (IRET), Universidad Nacional, Heredia, Costa Rica
| | - Luis Palomo-Cordero
- Infants Environmental Health Program (ISA) Central American Institute for Studies on Toxic Substances (IRET), Universidad Nacional, Heredia, Costa Rica
| | - Jorge Peñaloza-Castañeda
- Infants Environmental Health Program (ISA) Central American Institute for Studies on Toxic Substances (IRET), Universidad Nacional, Heredia, Costa Rica
| | - Jane A Hoppin
- Department of Biological Sciences, NC State University, Raleigh, NC, USA; Center for Human Health and the Environment, NC State University, Raleigh, NC, USA.
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Elonheimo HM, Mattila T, Andersen HR, Bocca B, Ruggieri F, Haverinen E, Tolonen H. Environmental Substances Associated with Chronic Obstructive Pulmonary Disease-A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:3945. [PMID: 35409627 PMCID: PMC8997594 DOI: 10.3390/ijerph19073945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/16/2022] [Accepted: 03/23/2022] [Indexed: 12/13/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a slowly developing non-communicable disease (NCD), causing non-reversible obstruction and leading to marked morbidity and mortality. Besides traditional risk factors such as smoking, some environmental substances can augment the risk of COPD. The European Human Biomonitoring Initiative (HBM4EU) is a program evaluating citizens' exposure to various environmental substances and their possible health impacts. Within the HBM4EU, eighteen priority substances or substance groups were chosen. In this scoping review, seven of these substances or substance groups are reported to have an association or a possible association with COPD. Main exposure routes, vulnerable and high-exposure risk groups, and matrices where these substances are measured are described. Pesticides in general and especially organophosphate and carbamate insecticides, and some herbicides, lead (Pb), and polycyclic aromatic hydrocarbons (PAHs) showed an association, and cadmium (Cd), chromium (Cr and CrVI), arsenic (As), and diisocyanates, a possible association with COPD and/or decreased lung function. Due to long latency in COPD's disease process, the role of chemical exposure as a risk factor for COPD is probably underestimated. More research is needed to support evidence-based conclusions. Generally, chemical exposure is a growing issue of concern, and prompt action is needed to safeguard public health.
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Affiliation(s)
- Hanna Maria Elonheimo
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare (THL), 00271 Helsinki, Finland; (T.M.); (E.H.); (H.T.)
| | - Tiina Mattila
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare (THL), 00271 Helsinki, Finland; (T.M.); (E.H.); (H.T.)
- Department of Pulmonary Diseases, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, 00029 Helsinki, Finland
| | - Helle Raun Andersen
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, DK-5000 Odense, Denmark;
| | - Beatrice Bocca
- Department of Environment and Health, Istituto Superiore di Sanità, 00161 Rome, Italy; (B.B.); (F.R.)
| | - Flavia Ruggieri
- Department of Environment and Health, Istituto Superiore di Sanità, 00161 Rome, Italy; (B.B.); (F.R.)
| | - Elsi Haverinen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare (THL), 00271 Helsinki, Finland; (T.M.); (E.H.); (H.T.)
| | - Hanna Tolonen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare (THL), 00271 Helsinki, Finland; (T.M.); (E.H.); (H.T.)
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