Association of indoor and outdoor particulate level with chronic respiratory illness

Indoor air quality and thermal comfort-results of a pilot study in elderly care centers in Portugal

The age of the European population is rising and percentage of adults aged 65 years and older is projected to increase from 16% in 2000 to 20% in 2020. It has been estimated that older subjects spend approximately 19 to 20 h/d indoors. Older individuals may be particularly at risk for detrimental effects from pollutants, even at low concentrations, due to reduced immunological defenses and multiple underlying chronic diseases. Six Porto, Portugal, urban area elderly care centers (ECC), housing a total of 425 older persons, were studied to assess indoor air quality (IAQ) and thermal comfort (TC) in two seasons. This study presents the IAQ and TC results in 36 rooms and constitutes part of a wider and ongoing study. The study areas were all naturally ventilated, and indoor concentrations in winter were within Portuguese reference values. However, 42% of the participants were dissatisfied with indoor thermal conditions, rating it "slightly cool." In summer, the index rate of dissatisfied individuals was lower (8%). Significant differences were found between seasons in predicted percent of dissatisfied people (PPD) and predicted mean vote (PMV) indices. Fungal concentrations frequently exceeded reference levels (>500 colony-forming units [CFU]/m(3)). In addition, other pollutants occasionally exceeded reference levels. To our knowledge, this is the first study in Portugal to assess effects of indoor air contaminants on the health status and quality of life in older subjects living in ECC. Although IAQ and TC parameters were mostly within reference values, the results suggest a need to improve the balance between IAQ and TC in ECC, a critical environment housing a susceptible population.

Prevalence of chronic bronchitis-asthma symptoms in biomass fuel exposed females

OBJECTIVES

We investigated whether exposure to biomass fuel is a potential risk factor for chronic bronchitis and asthma among females in rural area in Van (east Turkey).

METHODS

The effect of indoor pollution producing various respiratory symptoms was studied in 177 females. Of these, 90 were those who used biomass fuel and 87 were nonusers of biomass fuel. A part of the European Community Respiratory Health Survey quastionnaire and British Medical Research Council questionnaire were used.

RESULTS

Asthma related symptoms (AS) (wheezing, and combination of wheezing without a cold and wheezing with breathlessness) were reported in 63.3% of those who used biomass fuel, and in 12.9% of nonusers (p<0.0001). The use of asthma medication was reported as 3.3% of biomass fuel users, and in 2.7% of nonuser (p>0.05). Long term cough and/or morning cough together with sputum (chronic bronchitis symptoms (BS) was reported as 58.9% in the user group, and 29.4% in the nonuser group (p<0.0001). Significant differences in AS and BS were found between biomass fuel user and nonuser groups in the rural area.

CONCLUSIONS

The results of this study showed a significant association between symptoms of chronic bronchitis-asthma and biomass fuel usage in females living in a rural area.

Indoor air pollution and self-reported diseases - a case study of NCT of Delhi

People in modern societies often spend 80-90% of their time in indoor environments. It is, therefore, imperative to analyze indoor air quality (IAQ) and its determinants and to consider the contribution of IAQ to possible health outcomes at the household level. Based on empirical data collected from 5949 households from 35 wards of Delhi, it can be summarized that higher proportions of residents live in degraded indoor environmental conditions. The highest risks to health were attached to use of traditional fuels (64%), lack of a kitchen (59%), exposure to environmental tobacco smoke (ETS) (55%), and poor ventilation (55%). Acute respiratory infections (43%) were identified as one of the most prevalent health problems confronted by residents and are strongly associated with use of traditional fuels (adjusted OR 2.7, 95% CI 2.3-3.1). Asthma shows a significant relationship with the use of traditional fuels (adjusted OR 3.8, 95% CI 3.4-4.3), exposure to ETS (adjusted OR 2.5, 95% CI 2.2-2.7), and poor ventilation (adjusted OR 1.26, 95% CI 1.13-1.41). Lung cancer (adjusted OR 1.54, 95% CI 1.38-1.71) and cardiovascular diseases (adjusted OR 2.25, 95% CI 2.01-2.53) also show a strong relationship with ETS exposure. More research is needed.

PRACTICAL IMPLICATIONS

The present study can help to create new insights in understanding the gravity of indoor air quality problems in Delhi and can therefore provide interesting material to social scientists, public health officers, planners, and decision makers. The information can be utilized to help formulate comprehensive policies and planning with a humanistic approach for proper urban indoor environments that will be applicable at all administrative levels, viz. local, national, and international, and will also provide an important background for additional research in this area.

Monetary burden of health impacts of air pollution in Mumbai, India: implications for public health policy

OBJECTIVES

Mumbai, a mega city with a population of more than 12 million, is experiencing acute air pollution due to commercial activity, a boom in construction and vehicular traffic. This study was undertaken to investigate the link between air pollution and health impacts for Mumbai, and estimate the monetary burden of these impacts.

STUDY DESIGN

Cross-sectional data were subjected to logistic regression to analyse the link between air pollution and health impacts, and the cost of illness approach was used to measure the monetary burden of these impacts.

METHODS

Data collected by the Environmental Pollution Research Centre at King Edward Memorial Hospital in Mumbai were analysed using logistic regression to investigate the link between air pollution and morbidity impacts. The monetary burden of morbidity was estimated through the cost of illness approach. For this purpose, information on treatment costs and foregone earnings due to illness was obtained through the household survey and interviews with medical practitioners.

RESULTS

Particulate matter (PM(10)) and nitrogen dioxide (NO(2)) emerged as the critical pollutants for a range of health impacts, including symptoms such as cough, breathlessness, wheezing and cold, and illnesses such as allergic rhinitis and chronic obstructive pulmonary disease (COPD). This study developed the concentration-response coefficients for these health impacts. The total monetary burden of these impacts, including personal burden, government expenditure and societal cost, is estimated at 4522.96 million Indian Rupees (INR) or US$ 113.08 million for a 50-μg/m(3) increase in PM(10), and INR 8723.59 million or US$ 218.10 million for a similar increase in NO(2).

CONCLUSIONS

The estimated monetary burden of health impacts associated with air pollution in Mumbai mainly comprises out-of-pocket expenses of city residents. These expenses form a sizable proportion of the annual income of individuals, particularly those belonging to poor households. These findings have implications for public health policy, particularly accessibility and affordability of health care for poor households in Mumbai. The study provides a rationale for strengthening the public health services in the city to make them more accessible to poor households, especially those living in the slums of Mumbai.

Indoor air pollution and childhood asthma: variations between urban and rural areas

Health effects of indoor pollution have been investigated overall in urban areas. To compare the potential effect of home air pollutants on asthma in urban and rural houses, two case-control populations, composed of children living in the city (32 asthmatics and 31 controls) and in the countryside (24 asthmatics and 27 controls) were included. During 1 week, nitrogen dioxide, fine particles, and volatile organic compounds (formaldehyde, acetaldehyde, benzene, toluene, ethylbenzene, and xylenes) were assessed at home. Urban dwellings were found to be more polluted than rural ones, with concentrations up to two times higher. In the whole population, exposure to acetaldehyde and toluene was significantly associated with a higher risk of asthma. In the urban population, the association with toluene was significant in children studied during winter, and with toluene, xylenes, and ethylbenzene when cases were restricted to current asthmatics. In rural settings, a relationship between asthma and formaldehyde exposure was observed (OR = 10.7; 95% CI 1.69-67.61). Our findings suggest that daily continuous exposures to pollutants may be implicated in asthma, even in the case of low exposure, as those found in rural areas. Our results could also indicate a specific effect of indoor pollution in the rural environment.

PRACTICAL IMPLICATIONS

Everyday exposure to indoor pollution was associated with a higher risk of childhood asthma. These findings suggest that even at low concentrations, pollutants could be implicated in asthma and reinforce the importance of establishing guideline values to improve indoor air quality by limiting sources or by optimizing ventilation. Specific effects could occur in rural environments where pollution differs from urban area.

Respiratory responses to diverse indoor combustion air pollution sources

Diverse indoor combustion sources contribute to the indoor air environment. To evaluate the effect of these sources on human respiratory health, we examined associations between respiratory conditions and household factors in the 2360 children's fathers (mean = 38.4 years old) and associations between lung function and household factors in 463 primary school children (mean = 8.3 years old) from Wuhan, China. Factor analysis developed new uncorrelated 'factor' variables. Unconditional logistic regression models or linear regression models, controlling for important covariates, estimated the respiratory health effects. Coal smoke derived from home heating ('heating coal smoke') was associated with high adult reporting of persistent cough, persistent phlegm, and wheeze. Cooking coal smoke was associated with physician-diagnosed adult asthma and decreased forced vital capacity (FVC), and forced expiratory volume at 1 s (FEV(1)) in children. The presence of any home cigarette smoker was associated with more reports of persistent cough, persistent phlegm, cough with phlegm, and bronchitis. Our study suggests that in Wuhan, there may be independent respiratory health effects of different indoor combustion sources and their exposure factors for these study populations.

PRACTICAL IMPLICATIONS

We conclude that multiple indoor air pollution sources could have adverse respiratory health effects on both children and middle-aged men in the city of Wuhan, China. These results may have implications for the Wuhan local government, the Chinese government, or other related organizations in efforts on protecting public health through regulation of indoor air pollution from indoor combustion sources.

Health benefit evaluation of the energy use scenarios in Beijing, China

Air pollution is one of the important causal factors for excess cardiorespiratory deaths and diseases. However, little information is available on health gains from clean energy usage in developing countries. In this study the expected population exposed to air pollutants was estimated under the different energy use scenarios by the year 2010, 2020 and 2030, respectively, in the urban area of Beijing, China. The concentration-response functions between air pollutants and the health endpoints were established using meta-analysis and regression models. The decreased cardiorespiratory deaths and diseases of the exposed population were predicted as the health benefits from air pollution reduction. We used daily measurements of particulate matter less than 10 mum in aerodynamic diameter (PM(10)) and sulphate dioxide (SO(2)) as air pollution indicators. The percentage of population exposed to higher level of PM(10) will be decreased significantly under the clean energy use scenario than that under the Baseline Scenario (i.e., business-as-usual scenario). Compared with the Baseline Scenario there will be, by 2010, 2020, and 2030, respectively, a decrease of 29-152, 30-212 and 39-287 acute excess deaths; and 340-1811, 356-2529 and 462-3424 chronic excess deaths associated with the reduction of PM(10) level; also a decrease of 237-331, 285-371 and 400-554 short-term excess deaths associated with the decrease of SO(2) level. Meanwhile, the number of respiratory and cardiovascular hospital admissions, outpatient visits to internal and paediatrics departments, total emergency room visits and asthma attacks will be remarkably reduced with the reduction of air pollution. Energy structure improvement could reduce ambient air pollution and produce substantial health benefits to the population in Beijing. These findings may have significant implications for other metropolitan cities, particularly in developing countries.

Potential health benefit of reducing household solid fuel use in Shanxi province, China

Indoor air pollution from solid fuel use has severe health effects. 60% of the Chinese population lives in rural areas, where most people rely on solid fuels for cooking and heating. We estimate exposure by combining information on the amount of time spent in different microenvironments and estimates of the particle concentrations (PM(10)) in these environments. According to our estimates, 70% of the exposure experienced by the rural population is due to indoor air pollution (IAP). The urban coal using population experience a 17% increase in exposure from IAP. We apply Monte Carlo simulations to quantify variability and uncertainty in the exposure, morbidity and mortality estimates. We find that applying Monte Carlo simulations reduces the estimated uncertainty compared to analytical methods based on approximate distributions and the central limit theorem. We find that annually about 4% (geometric S.D. sigma(g), 3.2) and 35% (sigma(g), 2.6) of the deaths in the urban and rural populations, respectively, could be avoided by switching to clean fuels. Upgrading the stoves in rural areas to the standard found in urban areas is estimated to reduce mortality by 23% (sigma(g), 3.1). Moreover, we estimate that chronic respiratory illness (CRI) in children can be reduced by, respectively, about 9% (sigma(g), 2.5) and 80% (sigma(g) 1.9) by switching to clean fuels in the urban and rural areas. Upgrading the stoves in rural areas is estimated to reduce CRI in children with about 58% (sigma(g) 2.3). For adults the reduction in CRI was estimated to be 6% (sigma(g) 2.4) and 45% (sigma(g) 1.8) for the urban and rural population following a fuel switch, and 31% (sigma(g) 2.4) for the rural population from stove improvements. Contrary to our expectations we find small gender differences in exposure. We ascribe that to comparable kitchen and living area concentrations and similar indoor occupation times for the genders. Young children and the elderly spend the most time indoors, and have the highest daily exposure in the coal using population. The rural population experience higher exposure than the urban population, even though the outdoor air is significantly cleaner in rural areas.

Respiratory symptoms in relation to residential coal burning and environmental tobacco smoke among early adolescents in Wuhan, China: a cross-sectional study

BACKGROUND

Cigarette smoking and coal burning are the primary sources of indoor air pollution in Chinese households. However, effects of these exposures on Chinese children's respiratory health are not well characterized.

METHODS

Seventh grade students (N = 5051) from 22 randomly selected schools in the greater metropolitan area of Wuhan, China, completed an in-class self-administered questionnaire on their respiratory health and home environment.

RESULTS

Coal burning for cooking and/or heating increased odds of wheezing with colds [odds ratio (OR) = 1.57, 95% confidence interval (CI): 1.07-2.29] and without colds (OR = 1.44, 95% CI: 1.05-1.97). For smoking in the home, the strongest associations were seen for cough (OR = 1.74, 95% CI: 1.17-2.60) and phlegm production (OR = 2.25, 95% CI: 1.36-3.72) without colds among children who lived with two or more smokers.

CONCLUSIONS

Chinese children living with smokers or in coal-burning homes are at increased risk for respiratory impairment. While economic development in China may decrease coal burning by providing cleaner fuels for household energy use, the increasing prevalence of cigarette smoking is a growing public health concern due to its effects on children. Adverse effects of tobacco smoke exposure were seen despite the low rates of maternal smoking (3.6%) in this population.

Exposure-response functions for health effects of ambient air pollution applicable for China -- a meta-analysis

Assessing the benefits of projects and policies to reduce air pollution requires quantitative knowledge about the relationship between exposure to air pollution and public health. This article proposes exposure-response functions for health effects of PM10 and SO2 pollution in China. The functions are based on Chinese epidemiological studies, and cover mortality, hospital admissions, and chronic respiratory symptoms and diseases. We derive the following coefficients for acute effects: a 0.03% (S.E. 0.01) and a 0.04% (S.E. 0.01) increase in all-cause mortality per microg/m3 PM10 and SO2, respectively, a 0.04% (S.E. 0.01) increase in cardiovascular deaths per microg/m3 for both PM10 and SO2, and a 0.06% (S.E. 0.02) and a 0.10% (S.E. 0.02) increase in respiratory deaths per microg/m3 PM10 and SO2, respectively. For hospital admissions due to cardiovascular diseases the obtained coefficients are 0.07% (S.E. 0.02) and 0.19% (S.E. 0.03) for PM10 and SO2, respectively, whereas the coefficients for hospital admissions due to respiratory diseases are 0.12% (S.E. 0.02) and 0.15% (S.E. 0.03) for PM10 and SO2, respectively. Exposure-response functions for the impact of long-term PM10 levels on the prevalence of chronic respiratory symptoms and diseases are derived from the results of cross-sectional questionnaire surveys, and indicate a 0.31% (S.E. 0.01) increase per microg/m3 in adults and 0.44% (S.E. 0.02) per microg/m3 in children. With some exceptions, Chinese studies report somewhat lower exposure-response coefficients as compared to studies in Europe and USA.

Indoor exposures and acute respiratory effects in two general population samples from a rural and an urban area in Italy

A study of indoor air exposures and acute respiratory effects in adults was conducted in the Po Delta (rural) and Pisa (urban) areas of Italy. Indoor exposures were monitored for nitrogen dioxide (NO(2)) and particulate matter <2.5 microm (PM(2.5)) for 1 week during the winter or summer in a total of 421 houses (2/3 in Pisa). Information on house characteristics, subjects' daily activity pattern and presence of acute respiratory symptoms was collected by a standardized questionnaire. Peak expiratory flow (PEF) maneuvers were performed by adult subjects four times daily; maximum amplitude and diurnal variation were taken into account. Indices of NO(2) and PM(2.5) exposures were computed as the product of weekly mean pollutant concentration by the time of daily exposure. Mean levels of pollutants were significantly higher in winter than in summer, regardless of the area. The relationship between exposure indices and acute respiratory symptoms was investigated only in winter. In spite of a slightly lower indoor level in the urban than in the rural area in winter (NO(2): 15 vs. 22 ppb; PM(2.5): 67 vs. 76 microg/m(3)), prevalence rates of acute respiratory symptoms were significantly higher in the urban than in the rural area. Acute respiratory illnesses with fever were significantly associated with indices of NO(2) (odds ratio (OR)=1.66; 95% CI=1.08-2.57) and PM(2.5) exposures (OR=1.62; 95% CI=1.04-2.51), while bronchitic/asthmatic symptoms were associated only with PM(2.5) (OR=1.39; 95% CI=1.17-1.66). PEF variability was positively related only to PM(2.5) exposure index (OR=1.38; 95% CI=1.24-1.54, for maximum amplitude; OR=1.37; 95% CI=1.23-1.53, for diurnal variation). In conclusion, indoor pollution exposures were associated with the presence of acute respiratory symptoms and mild lung function impairment in a rural and an urban area of Northern-Central Italy.

Exposure-response relationships between lifetime exposure to residential coal smoke and respiratory symptoms and illnesses in Chinese children

Data collected in a large epidemiologic study were analyzed to examine respiratory health effects of residential coal use in 7058 school children living in the four Chinese cities of Chongqing, Guangzhou, Lanzhou, and Wuhan. A Scenario Evaluation Approach was used to develop two exposure variables, heating coal smoke and cooking coal smoke. Estimated lifetime exposures to heating coal smoke and cooking coal smoke were both classified into four-level ordinal scales, as follows: no reported exposure (control); lightly exposed; moderately exposed; and heavily exposed. Zero-one dummy variables were constructed for each exposure level other than the control level (total six variables). These variables were entered into the analytical model. We tested for exposure-response relationships using logistic regression models, while controlling for other relevant covariates, including an indicator variable of ambient air pollution levels. We observed monotonic and positive exposure-response relationships of exposure to heating coal smoke with modeled odds ratios (ORs) of phlegm, cough with phlegm, and bronchitis. Other health outcomes were not associated with such exposure in a monotonic exposure-response pattern. However, ORs for cough, wheeze, and asthma were all higher in the exposed groups than in the control group. We observed no consistent associations between cooking coal smoke and the examined health outcomes. We conclude that exposure to heating coal smoke could have adverse effects on children's respiratory symptoms and illnesses in these four Chinese cities.

Quantifying the human health benefits of curbing air pollution in Shanghai

Urban development in the mega-cities of Asia has caused detrimental effects on the human health of its inhabitants through air pollution. However, averting these health damages by investing in clean energy and industrial technologies and measures can be expensive. Many cities do not have the capital to make such investments or may prefer to invest that capital elsewhere. In this article, we examine the city of Shanghai, China, and perform an illustrative cost/benefit analysis of air pollution control. Between 1995 and 2020 we expect that Shanghai will continue to grow rapidly. Increased demands for energy will cause increased use of fossil fuels and increased emissions of air pollutants. In this work, we examine emissions of particles smaller than 10 microm in diameter (PM10), which have been associated with inhalation health effects. We hypothesize the establishment of a new technology strategy for coal-fired power generation after 2010 and a new industrial coal-use policy. The health benefits of pollution reduction are compared with the investment costs for the new strategies. The study shows that the benefit-to-cost ratio is in the range of 1-5 for the power-sector initiative and 2-15 for the industrial-sector initiative. Thus, there appear to be considerable net benefits for these strategies, which could be very large depending on the valuation of health effects in China today and in the future. This study therefore provides economic grounds for supporting investments in air pollution control in developing cities like Shanghai.

Particulate air pollution and chronic respiratory symptoms among traffic policemen in Bangkok

In this cross-sectional study, the authors examined the relationship between traffic-based air pollution and chronic, nonspecific respiratory symptoms among traffic policemen in Bangkok, Thailand. A total of 1,603 policemen who lived and worked in areas that had 3 different levels of airborne particulates were evaluated. The authors used a modified standardized questionnaire to identify nonspecific respiratory disease (NSRD) in participants. The prevalence of NSRD in heavily polluted, moderately polluted, and suburban areas was 13.0%, 10.9%, and 9.4%, respectively. Among nonsmokers, the age-adjusted prevalence of NSRD in the heavily polluted areas was significantly higher than in the suburban control area. Also among nonsmokers, the odds ratio for NSRD for each 10-microg/m3 increase in ambient particulate matter was 1.11. The authors concluded that the increased prevalence of respiratory symptoms among traffic policemen in Bangkok was associated with urban traffic air pollution.

Respiratory symptoms and exposure to wood smoke in an isolated northern community

BACKGROUND

Wood smoke has been associated with respiratory symptoms. This study examined the prevalence of respiratory symptoms and health effects of wood smoke exposures (from home heating, curing meat, and tanning hides) among residents of Deline, Northwest Territories (NWT).

METHODS

A survey was conducted of all residents. Relationships between wood smoke and respiratory symptoms were examined.

RESULTS

The response rate was 70.2% (n=402). 71% of people at least 18 years old were current smokers. Prevalence of symptoms was higher for women (odds ratios (ORs) 1.3-3.1). Women who smoked were more likely to be exposed to indoor smoke from curing and tanning. ORs for respiratory symptoms were higher for females, increased with age, and were strongly affected by smoking. Among those at least 18 years old, phlegm on winter mornings (6.5 (95% CI: 2.3-18.1)), dyspnoea (5.1 (95% CI: 1.9-13.2)), and watery or itchy eyes (3.6 (95% CI: 1.4-9.0)) were significantly related to self-reported outdoor wood smoke and smoke curing. Home heating was marginally associated with wheeze. No significant associations were found for males.

CONCLUSIONS

Women engaged in curing/tanning demonstrated increased prevalence of respiratory symptoms. The cultural importance of these activities precludes abandoning them. Smoking cessation, limiting wood smoke exposure times, and process modifications in curing and tanning could reduce risk of adverse health effects.

Animal models of chronic bronchitis and their relevance to studies of particle-induced disease

Chronic bronchitis is a significant cause of morbidity and mortality. Chronic irritation of the conducting airways by inhaled substances, most importantly cigarette smoke, air pollution, and occupational exposures, is thought to be a key factor in the pathogenesis of chronic bronchitis. Microbial infections have been implicated in acute exacerbations of bronchitis and in its progression. Several animal models of chronic bronchitis have been developed. This review examines similarities and dissimilarities among commonly used animal models of bronchitis and the human disease. The most commonly used animal models of chronic bronchitis are those employing SO2, tobacco smoke, lipopolysaccharide (endotoxin), proteases, and secretagogues. Bronchiolitis induced by nickel and nitric acid have also been reported. Rats, hamsters, and dogs are the species most frequently used; sheep and monkeys have been used less frequently. These models vary in the extent or location of mucous-cell hyperplasia and metaplasia, airway inflammation, chronicity, ease of induction, and reproducibility. Frequently, the deficiencies in these models are attributable to anatomic differences between human and animal airways, differences in the severity or chronicity of inflammation or fibrosis, or lack of complete characterization of the responses and their time course in the animal model. These animal models may be useful for investigating how, and under what exposure conditions, ambient pollutants might exacerbate airway inflammation, mucus hypersecretion, and airflow limitation.

[Second consensus report on the use of antimicrobial agents in exacerbations of chronic obstructive pulmonary disease]

Aware of the importance of chronic obstructive pulmonary disease (COPD), a panel of experts belonging to the Spanish Society of Respiratory Medicine and Thoracic Surgery (SEPAR), the Spanish Society of Chemotherapy (SEQ) and the Spanish Society of Family and Community Medicine (SEMFyC) issued a statement of consensus in 2000 to serve as the basis for adequate antibiotic control of the disease. Three years later, in accordance with significant scientific progress made in this area, the statement has been thoroughly revised. The new paper in fact constitutes a second consensus statement on the use of antibiotics in COPD exacerbations. When several scientific associations expressed interest in joining the project and contributing to it the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of General Medicine (SEMG) and the Spanish Society of Rural and General Medicine (SEMERGEN) their incorporation led SEPAR and SEMFyC to change the structure of the statement and certain aspects of its content. Additionally, a new group of antibiotics, the ketolides, has joined the therapeutic arsenal. Telithromycin, the single representative of the group for the moment, can be considered not only an alternative treatment but even the drug of choice in certain clinical settings that are analyzed in the new statement. Those developments, along with others, such as the increasingly recognized action of levofloxacin against Pseudomonas aeruginosa and the steady action of amoxicillin with clavulanic acid when administered at recommended doses every 8 hours, provide new antimicrobial therapeutic protocols for COPD. Finally, the statement includes a scientific analysis of other groups of antimicrobial agents (macrolides, oral cephalosporins, etc.) and guidelines for both primary care physicians and specialists to follow when prescribing them.

Diesel exhaust particle-induced cell death of cultured normal human bronchial epithelial cells

We investigated the effect of diesel exhaust particles (DEPs) on normal human bronchial epithelial (NHBE) cells. Inclusion of DEPs in culture media was lethal to NHBE cells. NHBE cells are more susceptible to DEPs than other normal human lung cells, normal human pulmonary artery endothelial cells and normal human embryonic lung fibroblasts. DEP-induced cell death was mainly due to necrosis. Using the fluorescence probes diacetoxymethyl 6-carboxy-3',6'-diacetoxy-2',7'-dichloro-3',6'-dideoxydihydrofluorescinate and 4,5-diaminofluorescein diacetate, it was observed that hydrogen peroxide and nitrogen monoxide, respectively, were generated within DEP-exposed NHBE cells. DEP cytotoxicity increased or decreased with an increase or decrease in the cellular level of reduced glutathione (GSH) by treatment with L-buthionine-(R,S)-sulfoximine or ethyl reduced glutathionate, respectively. In addition, DEPs themselves decreased the cellular level of GSH in a dose-dependent manner. Upon exposure of NHBE cells to high concentrations of DEPs, their cellular GSH was depleted almost throughout. Further, the following agents decreased DEP cytotoxicity: 1) antioxidants 2,2,5,7,8-pentamethylchroman-6-ol, ebselen, and N,N'-bis(salicylidene)ethylenediaminomanganese(II) dihydrate (EUK-8); 2) iron ion-chelating agents disodium bathophenanthrolinedisulfonate and desferrioxamine mesylate; 3) nitrogen monoxide synthase inhibitors N(G)-nitro-L-arginine methyl ester hydrochloride and N(G)-methyl-L-arginine acetate salt; and 4) an endocytosis inhibitor quinacrine. On the basis of these observations, the mechanism of DEP cytotoxicity toward NHBE cells is discussed.

Wood stove heating, asthma and allergies

In two German studies household wood or coal stove use was negatively associated with atopic sensitization and allergic rhinitis in childhood. Wood stove heating is strongly related to 'traditional lifestyle and therefore subjected to confounding factors possibly yet not known. The study was conducted to study these factors and the independent impact of early exposure to wood stove heating on subsequent asthma and atopic disease. In a questionnaire survey among 10667 Finnish university students aged 18-25 years, we investigated the association between wood stove heating at age 0-6 years and asthma and allergies up to young adulthood. Adjustment was made for factors related to the heating system and atopic disorders by using multivariate regression. Unadjusted lifetime prevalence rates for physician-diagnosed asthma, allergic rhinoconjunctivitis, atopic dermatitis and self-reported wheezing were lower among subjects with wood stove heating compared to other heating systems. There was a significant negative association between childhood wood stove heating and allergic rhinitis or conjunctivitis in the univariate model (OR 0.61, 95% CI 0.61-0.91), but not for the other diseases. The significant association disappeared in the multivariate analysis after adjusting for various family indoor and outdoor (adjusted OR 0.96, 95% CI 0.77-1.20) factors. The association between wood stove heating and allergic rhinoconjunctivitis was mainly confounded by childhood residential environment, especially the farm environment. Farm environment was found to be the main confounding factor related to association between wood stove heating and asthma, and atopic diseases.

Diesel exhaust particle-induced cell death of human leukemic promyelocytic cells HL-60 and their variant cells HL-NR6

The cytotoxicity of diesel exhaust particles (DEPs) toward human leukemic promyelocytic cells HL-60 was examined. DEPs were toxic and cytotoxicity increased in a dose-dependent manner. All cells died with 750 microg/ml DEPs in culture media. Apoptosis occurred in HL-60 cells exposed to DEPs. The cytotoxicity of DEP extracts with organic solvents was much lower than those of DEPs and organic solvent-washed residual DEPs. HL-NR6 cells, an HL-60 variant cell line, having higher superoxide dismutase and catalase activities than HL-60 cells, were more resistant to DEP cytotoxicity. When preincubated with the fluorescent probe diacetoxymethyl 6-carboxy-2',7'-dichlorodihydrofluorescinate diacetate and then exposed to DEPs, HL-60 cells emitted green fluorescence under blue illumination, indicating that reactive oxygen species were generated within the cells. The DEP cytotoxicity correlated inversely with the cellular concentration of reduced glutathione (GSH), which had been attenuated with L-buthionine-(R,S)-sulfoximine, a gamma-glutamylcysteine synthetase inhibitor, and was lowered with ethyl reduced glutathionate, a GSH carrier across biomembranes. Further, DEPs themselves decreased the cellular concentration of GSH in a dose-dependent manner. The alpha-tocopherol model compound 2,2,5,7,8-pentamethylchroman-6-ol decreased DEP cytotoxicity, while alpha-tocopherol had no effect. In addition, quinacrine, an endocytosis inhibitor, decreased DEP cytotoxicity. These results show that DEPs are cytotoxic and suggest that the cytotoxicity results from generation of reactive oxygen species by DEPs which have been incorporated into cells.

Smoking, respiratory symptoms, and diseases : a comparative study between northern Sweden and northern Finland: report from the FinEsS study

STUDY OBJECTIVES

The influences of different smoking categories on the prevalence of respiratory symptoms, asthma, and chronic bronchitis have been examined in the most northern province of Sweden, Norrbotten, and in Lapland, Finland. The two areas have similar geographic and demographic conditions.

METHODS AND STUDY POPULATION

The study is a part of the FinEsS studies, which are epidemiologic respiratory surveys in progress in Sweden, Finland, and Estonia. A random sample of 20- to 69-years-olds were invited to answer a postal questionnaire about respiratory symptoms, smoking habits, and occupation. In Norrbotten, 8,333 subjects were invited and 7,104 responded (85%). In Lapland, 8,005 were invited and 6,633 responded (83%).

RESULTS

The participation by age and sex was similar in both countries. The prevalence of smokers in Lapland was 32% vs 26% in Norrbotten. Significantly more women than men in Norrbotten were smokers, while the opposite was true for Lapland. Sputum production was the most prevalent symptom in both areas, 25% in Lapland vs 19% in Norrbotten. The prevalence of chronic productive cough was 11% in Lapland and 7% in Norrbotten. Bronchitic symptoms were more prevalent in Lapland among both smokers and nonsmokers. A positive family history of chronic obstructive airway disease together with increased number of consumed cigarettes showed an additive effect for both chronic productive cough and wheezing. The odds ratio (OR) for wheezing during the last 12 months was 3.8 for subjects without a family history of obstructive airway disease who consumed > 14 cigarettes per day compared with nonsmokers, but if the subjects had a family history of obstructive airway disease, the risk for wheezing increased to OR 8.4.

CONCLUSION

Bronchitic symptoms were more common in Finland. The difference remained also after correction for demographic variables including smoking habits, age and socioeconomic group, and family history of obstructive airway disease. Identical methods, sample composition, and the high participation rate contribute to the validity of the results. Air pollution, including environmental tobacco smoke, may contribute to the difference. To explain the difference, further analysis and investigations of social and environmental factors as well as genetic factors are needed.

Effects of air pollution on children's respiratory health in three Chinese cities

During the winter of 1988-1989, parents of 2,789 elementary-school students completed standardized questionnaires. The students were 5-14 y of age and were from three urban districts and one suburban district of three large Chinese cities. The 4-y average ambient levels of total suspended particles in the three cities differed greatly during the period 1985-1988: Lanzhou, 1,067 microg/m3; urban Wuhan, 406 microg/m3; Guangzhou, 296 microg/m3; and suburban Wuhan, 191 microg/m3. The authors constructed unconditional logistic-regression models to calculate odds ratios and 95% confidence intervals for prevalences of several respiratory symptoms and illnesses, adjusted for district, use of coal in the home, and parental smoking status. There was a positive and significant association between total suspended particle levels and the adjusted odds ratios for cough, phlegm, hospitalization for diseases, and pneumonia. This association was derived from only the 1,784 urban children and, therefore, the authors were unable to extrapolate it to the suburban children. The results also indicated that parental smoking status was associated with cough and phlegm, and use of coal in the home was associated only with cough prevalence (alpha = 0.05).

Effects of air pollution on respiratory health of adults in three Chinese cities

The authors examined potential associations between air-pollution exposures and respiratory symptoms and illnesses of 4,108 adults who resided in 4 districts of 3 large, distinct Chinese cities. Data on respiratory health outcomes and relevant risk factors for parents and children were obtained via standardized questionnaires in the winter of 1988. (The effects in children were described previously.) The yearly averages of ambient levels of total suspended particles in the 4 districts for the years 1985-1988 differed greatly. The authors constructed logistic-regression models to assess the respiratory health parameters of parents of the children. The results revealed significant and strong effects, by district, on prevalence rates of cough, phlegm, persistent cough and phlegm, and wheeze for both the mothers and the fathers. In addition, the odds ratios increased as ambient total suspended particle concentration increased across the 3 urban districts. Other local within-city risk factors, however, may have confounded the total suspended particles-effects association, especially for asthma prevalence. Findings for adults were similar to those found for their children. A strong adverse effect of active tobacco smoking on the fathers' respiratory health was observed. The children appeared to be more strongly affected by passive smoking exposure received in their homes than their mothers.

Particulate matter, sulfur dioxide, and pulmonary function in never-smoking adults in Chongqing, China

Chongquing is one of the most polluted cities in China. To study the respiratory health effects of air pollution for this city, the authors monitored the ambient levels of particulate matter (PM2.5) and sulfur dioxide (SO2) in urban and suburban areas and performed pulmonary function testing on 1,075 adults 35 to 60 years of age who had never smoked and did not use coal stoves for cooking or heating. The mean concentration of SO2 in the urban areas (213 micrograms/m3) was twice as high as that in suburban areas (103 micrograms/m3). Mean PM2.5 levels were high in both urban (143 micrograms/m3) and suburban (139 micrograms/m3) areas. A generalized additive model was used to estimate the differences between the two areas in FEV1, FVC, and FEV1/FVC%, with adjustment for potential confounding factors, including sex, age, height, education, passive smoking, and occupational exposures to dust, gas, or fumes. Estimated differences in FEV1 between the urban and suburban areas were 199 mL (SE = 50 mL) for men and 87 mL (SE = 30 mL) for women, both statistically significant. When the men and women were pooled, the estimated difference in FEV1 was 126 mL (SE = 27 mL). Similar trends were observed for FVC and FEV1/FVC%. After exclusion of 104 subjects with histories of occupational exposures to dust, gas, or fumes, the estimated difference was some-what smaller than that of the total samples. However, the effects on FEV1 and FEV1/FVC% remained significant for both men and women.

Mortality among residents near cokeworks in Great Britain

OBJECTIVES

To investigate whether residents near cokeworks have a higher standardised mortality than those further away, particularly from cardiovascular and respiratory causes, which may be associated with pollution from cokeworks.

METHOD

Cross sectional small area study with routinely collected postcoded mortality data and small area census statistics. Populations within 7.5 km of 22 cokeworks in Great Britain, 1981-92. Expected numbers of deaths within 2 and 7.5 km of cokeworks, and in eight distance bands up to 7.5 km of cokeworks, were calculated by indirect standardisation from national rates stratified for age and sex and a small area deprivation index, and adjusted for region. Age groups examined were all ages, 1-14, 15-64, 65-74, > or = 75. Only the 1-14 and 15-44 age groups were examined for asthma mortality.

RESULTS

There was a 3% (95% confidence interval (95% CI) 1% to 4%) excess of all deaths within 2 km of cokeworks, and a significant decline in mortality with distance from cokeworks. The excess of deaths within 2 km was slightly higher for females and elderly people, but excesses within 2 km and declines in risk with distance were significant for all adult age groups and both sexes. The size of the excess within 2 km was 5% (95% CI 3% to 7%) for cardiovascular causes, 6% (95% CI 3% to 9%) for ischaemic heart disease, and 2% (95% CI -2% to 6%) for respiratory deaths, with significant declines in risk with distance for all these causes. There was a non-significant 15% (95% CI -1% to 101%) excess in asthma mortality in the 15-44 age group. There were no significant excesses in mortality among children but 95% CIs were wide. Within 2 km of cokeworks, the estimated additional excess all cause mortality for all ages combined related to region and mainly to the greater deprivation of the population over national levels was 12%.

CONCLUSIONS

A small excess mortality near cokeworks as found in this study is plausible in the light of current evidence about the health impact of air pollution. However, in this study the effects of pollution from cokeworks, if any, are outweighed by the effects of deprivation on weighed by the effects of deprivation on mortality near cokeworks. It is not possible to confidently exclude socioeconomic confounding or biases resulting from inexact population estimation as explanations for the excess found.

Air pollution in the Latrobe Valley and its impact upon respiratory morbidity

OBJECTIVE

To assess the relationship between air pollution and respiratory morbidity.

DESIGN

An ecological study of the daily hospital admissions abstracted for the 1988 calendar year. Air quality data, including nitrogen dioxide (NO2), sulphur dioxide (SO2), ozone (O3) and particulates, were obtained from the relevant authorities.

SETTING

Latrobe Valley, Victoria.

SUBJECTS

Hospital admissions for asthma and Chronic Obstructive Airways Disease. (COAD).

RESULTS

There were significant associations (r = 0.11 to 0.17) between airborne particles, nitrogen dioxide and respiratory morbidity. There was no significant relationship between any of the pollutants and asthma admissions. However, multi-variate analysis confirmed that NO2 and particulates were associated with admissions for COAD.

CONCLUSION

Respiratory morbidity appears to be affected even by the low air pollution levels in the Latrobe Valley.

Synergistic effects of air pollution and personal smoking on adult pulmonary function

There is strong evidence that air pollution and cigarette smoking adversely affect respiratory health, but it remains uncertain whether the joint effects of air pollution and smoking are additive or synergistic. The authors investigated the hypothesized synergistic effects of air pollution and personal smoking on pulmonary function in a random sample of 3287 adults (40-69 y of age) who resided in residential, industrial, and suburban areas in Beijing. The authors used multiple linear regression and adjusted for age, sex, height, education, indoor use of coal stoves, crowding within a house, occupational exposures, and passive smoking. The annual mean total suspended particulates for the period 1981-1985 in residential, industrial, and suburban areas were 389 microg/m3, 449 microg/m3, and 261 microg/m3, respectively, and the annual mean sulfur dioxide levels were 128 microg/m3, 57 microg/m3, and 18 microg/m3, respectively. Compared with individuals in the suburban area, never smokers who resided in the industrial area had a 26-ml (standard error = 39) reduction in forced expiratory volume in 1 s and a 150-ml (standard error = 42) reduction in forced vital capacity; however, smokers in the same area suffered an additional 53-ml (standard error = 38) reduction in forced expiratory volume in 1 s and a 65-ml (standard error = 41) reduction in forced vital capacity. Similarly, never-smokers who resided in the residential area had a 72-ml (standard error = 35) reduction in forced expiratory volume in 1 s and a 274-ml (standard error = 38) reduction in forced vital capacity, and smokers in the same area suffered an additional 75-ml (standard error = 39) reduction in forced expiratory volume in 1 s and a 107-ml (standard error = 42) reduction in forced vital capacity. Long-term exposure to high levels of particulate and sulfur dioxide in Beijing was associated with significantly reduced pulmonary function in both never smokers and smokers. However, the associations were significantly greater among smokers than among never smokers, indicating a synergistic effect of air pollution and personal smoking on adult pulmonary function.

Exposure-response functions for health effects of air pollutants based on epidemiological findings

Quantitative knowledge about health damage due to air pollution is an important element in analyses of cost-effective abatement strategies, and is also essential for setting Air Quality Standards. Epidemiological studies, in spite of the numerous problems connected to them, provide a reasonable basis for exposure-response functions in this context. On the basis of a literature review, exposure-response functions that relate ambient air pollutant concentrations to the frequency of various health effects are recommended in this paper. The following end-points were examined: Acute and chronic respiratory symptoms in children and adults, crude mortality, and lung cancer incidence. The effects are attributed to one indicator component, which in most cases is particles. A calculation procedure is suggested which makes it possible to estimate excess annual symptom-days for short-term effects using the annual average concentration.

Acute effects of total suspended particles and sulfur dioxides on preterm delivery: a community-based cohort study

The acute effects of air pollution on preterm delivery were examined in a prospective cohort in Beijing, China. From early pregnancy until delivery in 1988, we followed all registered pregnant women who lived in four residential areas of Beijing. Information for both mothers and infants was collected. Daily air pollution and meteorological data were obtained independently. The sample for analysis included 25,370 resident women who gave first live births in 1988. Multiple linear regression and logistic regression were used to estimate the effects of air pollution on gestational age and preterm delivery (i.e., < 37 wk), with adjustment for outdoor temperature and humidity, day of the week, season, maternal age, gender of child, and residential area. Very high concentrations of ambient sulfur dioxide (mean = 102 micrograms/m3, maximum = 630 micrograms/m3) and total suspended particulates (mean = 375 micrograms/m3, maximum = 1 0003 micrograms/m3) were observed in these areas. There was a significant dose-dependent association between gestational age and sulfur dioxide and total suspended particulate concentrations. The estimated reduced duration of gestation was .075 wk (12.6h) and .042 wk (7.1 h) for each 100-micrograms/m3 increase in sulfur dioxide and total suspended particulates 7-d lagged moving average, respectively. The adjusted odds ratio for preterm delivery was 1.21 (95% CI = 1.01-1.46) for each in micrograms/m3 increase in sulfur dioxide, and was 1.10 (95% CI = 1.01-1.20) for each 100-micrograms/m3 increase in total suspended particulates. In addition, the gestational age distribution of high-pollution days was more skewed toward the left tail (i.e., very preterm and preterm), compared with low-pollution days. We concluded that high levels of total suspended particulates and sulfur dioxide, or of a more complex pollution mixture associated with these pollutants, appear to contribute to excess risk of preterm delivery in this population. Further work need to be carried out, with more detailed information on personal exposure and effect modifiers.

Association of air pollution with hospital outpatient visits in Beijing

Data collected at a community-based hospital in Beijing, China, were analyzed in an assessment of the association of air pollution with daily outpatient visits. Total suspended particle (TSP) measurements were available for 210 d (mean, 388 micrograms/m3; maximum, 1,255 micrograms/m3), and sulfur dioxide (SO2) measurements were available for 2 d (mean, 119 micrograms/m3; maximum, 478 micrograms/m3). The average number of daily hospital outpatient visits was 1,386; approximately 8.5% of these visits were to the surgery department, 7.9% were to the pediatrics department, and 20.6% were to the internal medicine department. A large increase in nonsurgery outpatient visits was observed in association with increases in both SO2 and TSP in linear regression models, after adjusting for temperature, humidity, season, and day of the week. The estimated effects (in which the most polluted days were compared with the least polluted days) on nonsurgery outpatient visits were increases of 20% (SE = 5%) and 17% (SE = 4%) in association with increases in SO2 and TSP, respectively. In a department-specific analysis, the association was found to be 1.5- to 2.0-fold stronger for pediatrics and internal medicine visits than for other types of visits. The separate associations of SO2 and TSP with internal medicine visits remained statistically significant when both SO2 and TSP were considered simultaneously and when adjustment was made for surgery visits. SO2 and TSP were found to be significant, independent predictors of internal medicine visits in both winter and summer.(ABSTRACT TRUNCATED AT 250 WORDS)