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Mansyur M, Fitriani DY, Prayogo A, Mutiara A, Asep, Fadhillah R, Aini R, Putri WW, Ramadhani SEF, Rubaya AK, Windarso SE, Santjoko H, Sudaryanto S, Haryono, Susilorini B, Hariojati N, Rodriguez A, Bose-O'Reilly S. Determinant Factors of Children's Blood Lead Levels in Java, Indonesia. Int J Hyg Environ Health 2024; 261:114426. [PMID: 39043055 DOI: 10.1016/j.ijheh.2024.114426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/08/2024] [Accepted: 07/15/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Lead poisoning contributes to a significant burden of disease as a toxic substance found in air, soil, and water. In Indonesia, the risk of exposure is high due to the inappropriate recycling of used lead batteries. The objective was to investigate the factors that influence lead levels in children's blood. METHODS This cross-sectional study assessed blood lead levels (BLLs) in children aged 12-59 months in four communities exposed to used lead-acid batteries (ULABs) recycling activities, comparing them to a control area. The study employed a threshold level of 20 μg/dL to identify high BLLs and utilized a sample size of 324 children from exposed sites and 240 from control sites. Questionnaires, blood lead tests and a home-based assessment for environmental exposures were applied. RESULTS The study participants comprised 295 boys and 269 girls, with an average age of 35 months. Significant disparities in soil lead concentrations median: Q1-Q3 were found between exposed (6581.7 : 2432.6-16647.1) ppm and control areas (253.5 : 158.8-417.1) ppm. Children in exposed areas had 3.9 times higher odds of BLL ≥20 μg/dL. Fathers with BLL ≥20 μg/dL had children with similarly elevated BLLs. Multivariate analysis identified socioeconomic status, study areas, environmental factors (cookware, food ware, spices, house cleaning), and children's behavior (breastfeeding duration) as determinants of elevated BLLs. Reported environmental factors had notable impact on BLLs, with aluminum cookware (aOR = 1.4, 95%CI [1.2-1.6]), food ware materials (aOR = 1.15, 95%CI [1.0-1.3]), type of spices (aOR = 2.7, 95%CI [1.7-48.0]), and house cleaning method (aOR = 2.9, 95%CI [1.2-7.1]). CONCLUSION This study highlighted key risk factors affecting children's blood lead levels (BLL) and emphasized the urgency of employing effective strategies to remediate lead-contaminated soils in exposed regions. The findings underscore the need for prompt medical intervention and monitoring for children in these areas, with additional research essential to fully understand lead poisoning pathways in the environment.
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Affiliation(s)
- Muchtaruddin Mansyur
- Occupational & Environmental Health Research Centre, Indonesian Medical and Education Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10430, Indonesia; Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10320, Indonesia.
| | - Dewi Yunia Fitriani
- Occupational & Environmental Health Research Centre, Indonesian Medical and Education Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10430, Indonesia; Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10320, Indonesia.
| | - Ari Prayogo
- Occupational & Environmental Health Research Centre, Indonesian Medical and Education Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10430, Indonesia; Tebet Regional Public Hospital, South Jakarta, 12810, Indonesia.
| | - Ade Mutiara
- Occupational & Environmental Health Research Centre, Indonesian Medical and Education Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10430, Indonesia; Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10320, Indonesia.
| | - Asep
- Occupational & Environmental Health Research Centre, Indonesian Medical and Education Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10430, Indonesia; Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10320, Indonesia.
| | - Ratih Fadhillah
- Occupational & Environmental Health Research Centre, Indonesian Medical and Education Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10430, Indonesia; Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10320, Indonesia.
| | - Rifka Aini
- Occupational & Environmental Health Research Centre, Indonesian Medical and Education Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10430, Indonesia; Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10320, Indonesia.
| | - Winda Widyaning Putri
- Occupational & Environmental Health Research Centre, Indonesian Medical and Education Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10430, Indonesia; Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10320, Indonesia.
| | - Sarah Edna Fadilah Ramadhani
- Occupational & Environmental Health Research Centre, Indonesian Medical and Education Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10430, Indonesia; Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, 10320, Indonesia.
| | | | | | - Herman Santjoko
- Health Polytechnic of Ministry of Health, Yogyakarta, 55293, Indonesia.
| | - Sigid Sudaryanto
- Health Polytechnic of Ministry of Health, Yogyakarta, 55293, Indonesia.
| | - Haryono
- Health Polytechnic of Ministry of Health, Yogyakarta, 55293, Indonesia.
| | - Budi Susilorini
- Yayasan Pure Earth Indonesia, Victorian Business Park, Block CC-09, 2nd Floor, Jl. Bintaro Utama 3A, Bintaro, Tangerang Selatan, Banten, 15221, Indonesia.
| | - Nickolaus Hariojati
- Yayasan Pure Earth Indonesia, Victorian Business Park, Block CC-09, 2nd Floor, Jl. Bintaro Utama 3A, Bintaro, Tangerang Selatan, Banten, 15221, Indonesia.
| | | | - Stephan Bose-O'Reilly
- Pure Earth, 475 Riverside Drive, New York, NY, 10115, USA; Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Ziemssenstr. 5, Munich, 80336, Germany.
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Kirichuk AA, Skalny AV, Chizhov AY, Tskhovrebov AG, Schaumlöffel D, Kritchenkov AS. Characteristic features of toxic metal content in hair samples of foreign students at RUDN University from different geographic regions. J Trace Elem Med Biol 2023; 80:127303. [PMID: 37741050 DOI: 10.1016/j.jtemb.2023.127303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND This study explores the regional variations in toxic metal accumulation among RUDN University students from various global regions. METHODS This comparative analysis examined hair samples from students hailing from different regions, including Russia, Asia, the Middle East, Africa, and Latin America. The concentrations of Aluminium (Al), Arsenic (As), Cadmium (Cd), Mercury (Hg), Lead (Pb), and Tin (Sn) were measured in the hair samples. The data was then evaluated using regression models to assess the link between the region of residence and toxic metal content in the hair. RESULTS The analysis indicated significant regional variations in the levels of toxic metals in the students' hair. The highest content of Al, Cd, and Pb was observed in students from Africa (13.542, 0.028, 0.794 µg/g) and Latin America (9.947, 0.025, 0.435 µg/g). Arsenic levels in students from all regions exceeded that of Russian students by over two-fold. No substantial group differences were found in the Sn content. The regression models suggested that residing in Asia, Africa, and Latin America was a predictor of high Hg levels in hair (0.130, 0.096, 0.227 µg/g). Living in Africa was significantly associated with higher Pb levels (0.794 µg/g), and living in Latin America was close to significantly associated with the Cd level in the hair (0.025 µg/g). CONCLUSION This study confirmed an increased accumulation of toxic metals, especially Hg, Cd, and Pb, in students primarily from Latin America and Africa. The findings highlighted the importance of understanding the regional variations in toxic metal accumulation to address associated health risks and the potential impact on students' well-being and academic performance. These insights may guide the development of targeted interventions to reduce exposure to toxic metals in students from various regions around the world.
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Affiliation(s)
- Anatoly A Kirichuk
- Peoples' Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya Street, Moscow 117198, Russian Federation
| | - Anatoly V Skalny
- Peoples' Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya Street, Moscow 117198, Russian Federation; Sechenov University, Moscow 119435, Russian Federation
| | - Aleksey Ya Chizhov
- Peoples' Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya Street, Moscow 117198, Russian Federation
| | - Alexander G Tskhovrebov
- Peoples' Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya Street, Moscow 117198, Russian Federation
| | - Dirk Schaumlöffel
- Peoples' Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya Street, Moscow 117198, Russian Federation; CNRS, Université de Pau et des Pays de l'Adour, E2S UPPA, Institut des Sciences Analytiques et de Physico-Chimie pour l'Environnement et les Matériaux (IPREM), UMR 5254, 64000 Pau, France
| | - Andreii S Kritchenkov
- Peoples' Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya Street, Moscow 117198, Russian Federation; Institute of Technical Acoustics NAS of Belarus, Ludnikova Prosp. 13, Vitebsk 210009, Republic of Belarus.
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Wati LR, Sargowo D, Nurseta T, Zuhriyah L, Rahardjo B. Correlations Among Maternal and Infant Factors, Lead Exposure, and Serum Prolactin Levels During Lactation: A Cross-sectional Study in Indonesia. J Prev Med Public Health 2023; 56:422-430. [PMID: 37735831 PMCID: PMC10579643 DOI: 10.3961/jpmph.23.238] [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: 05/20/2023] [Accepted: 07/28/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVES Prolactin is vital for breastfeeding and milk production, and its secretion is influenced by factors related to the mother, infant, and environment. To date, no study has concurrently investigated the correlation of these factors with serum prolactin levels during lactation. Therefore, the objective of this study was to investigate the correlations among maternal and infant factors, lead exposure, and serum prolactin levels during lactation. METHODS A cross-sectional approach was employed in Surabaya, Indonesia, among 110 exclusively lactating mothers. The mothers' daily diets were determined using multiple 24-hour recalls, while blood lead levels were measured with inductively coupled plasma mass spectrometry. Serum prolactin levels were assessed using the electrochemiluminescence immunoassay. For bivariate analysis, we employed the Spearman correlation, Mann-Whitney, and Kruskal-Wallis tests, while for multivariate analysis, we utilized multiple linear regression. RESULTS The average serum prolactin level of the lactating mothers was 129.19±88.96 ng/mL. Positive correlations were found between serum prolactin levels and breastfeeding frequency (p < 0.001), protein intake (p < 0.001), and calcium intake (p = 0.011) but had negative correlation with blood lead levels (p < 0.001) and vitamin B6 intake (p = 0.003). Additionally, prolactin levels were not significantly associated with maternal age; parity; intake of calories, vitamin D, vitamin E, zinc, folic acid, magnesium, or iron; infant age; or infant sex. CONCLUSIONS Breastfeeding frequency had a stronger positive relationship with serum prolactin levels than protein and calcium intake. However, lead exposure was associated with reduced serum prolactin levels during lactation. Consequently, specific interventions from policymakers are necessary to manage breastfeeding in mothers exposed to lead.
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Affiliation(s)
- Linda Ratna Wati
- Doctoral Study Program in Medical Science, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
- Department of Midwifery, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Djanggan Sargowo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya/Universitas Brawijaya Hospital, Malang, Indonesia
| | - Tatit Nurseta
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Lilik Zuhriyah
- Department of Public Health, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Bambang Rahardjo
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
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Barrozo F, de Almeida GA, Luz MS, Olympio KPK. A Low-Cost Method Shows Potentially Toxic Element Levels in Dust Correlated with Elevated Blood Levels of These Chemicals in Children Exposed to an Informal Home-Based Production Environment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16236. [PMID: 36498308 PMCID: PMC9735684 DOI: 10.3390/ijerph192316236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 06/17/2023]
Abstract
Dust is recognized as a route of exposure to environmental pollutants. The city of Limeira, Sao Paulo state, Brazil, is a production center for jewelry and fashion jewelry, where part of this jewelry production is home-based, informal, and outsourced. The aim of this study was to evaluate exposure to Potentially Toxic Elements (PTE: Cr, Sn, Mn, Sb, Ni, Cu, Zn, Cd, Pb, and As) in dust among children from households of informal workers using electrostatic dust cloths (EDC). Dust samples were collected in 21 exposed and 23 control families using EDC from surfaces where dust deposits had accumulated for approximately 14 days. In exposed families, dust samples were also collected from welders’ workstations. PTE concentrations were then determined using inductively coupled mass spectrometry (ICP-MS). The results raised concerns in relation to Cr, As, and Cd exposure among children within the informal home-based production environment. Blood PTE concentrations in children showed a moderate correlation with levels of Cr (Rho 0.40), Zn (Rho −0.43), and As (Rho 0.40), and a strong correlation with Cd (Rho 0.80) (p < 0.05), detected in dust. In conclusion, analyzing dust collected using EDC proved a potentially low-cost tool for determining PTE in dust. In addition, the results confirmed that informal home-based work poses a risk for children residing in these households. Public policies are needed to assist these families and promote better conditions of occupational health and safety for the whole family.
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Affiliation(s)
- Fairah Barrozo
- Department of Environmental Health, School of Public Health, University of São Paulo, Sao Paulo 01246-904, Brazil
| | - Gilmar Alves de Almeida
- Advanced Materials, Laboratory of Metallurgical Processes, Institute for Technological Research of the State of São Paulo, Sao Paulo 05508-901, Brazil
| | - Maciel Santos Luz
- Advanced Materials, Laboratory of Metallurgical Processes, Institute for Technological Research of the State of São Paulo, Sao Paulo 05508-901, Brazil
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Olufemi AC, Mji A, Mukhola MS. Potential Health Risks of Lead Exposure from Early Life through Later Life: Implications for Public Health Education. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192316006. [PMID: 36498077 PMCID: PMC9741093 DOI: 10.3390/ijerph192316006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/11/2022] [Indexed: 05/14/2023]
Abstract
Lead (Pb) exposure has been a serious environmental and public health problem throughout the world over the years. The major sources of lead in the past were paint and gasoline before they were phased out due to its toxicity. Meanwhile, people continue to be exposed to lead from time to time through many other sources such as water, food, soil and air. Lead exposure from these sources could have detrimental effects on human health, especially in children. UNICEF reported that approximately 800 million children have blood lead levels (BLLs) at or above 5 micrograms per deciliter (µg/dL) globally. This paper reports on the potential risks of lead exposure from early life through later life. The articles used in this study were searched from databases such as Springer, Science Direct, Hindawi, MDPI, Google Scholar, PubMed and other academic databases. The levels of lead exposure in low income and middle-income countries (LMICs) and high-income countries (HICs) were reported, with the former being more affected. The intake of certain nutrients could play an essential role in reducing (e.g., calcium and iron) or increasing (e.g., high fat foods) lead absorption in children. Elevated blood lead levels may disturb the cells' biological metabolism by replacing beneficial ions in the body such as calcium, magnesium, iron and sodium. Once these ions are replaced by lead, they can lead to brain disorders, resulting in reduced IQ, learning difficulties, reduced attention span and some behavioral problems. Exposure to lead at an early age may lead to the development of more critical problems later in life. This is because exposure to this metal can be harmful even at low exposure levels and may have a lasting and irreversible effect on humans. Precautionary measures should be put in place to prevent future exposure. These will go a long way in safeguarding the health of everyone, most especially the young ones.
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Vergara-Murillo F, Martinez-Yanez K, Fortich-Revollo A, Paternina-Caicedo A, Johnson-Restrepo B. Biochemical and Hematological Markers in Workers with Chronical Exposure to Lead and Cadmium in Colombia. TOXICS 2022; 10:524. [PMID: 36136488 PMCID: PMC9502882 DOI: 10.3390/toxics10090524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/01/2022] [Accepted: 08/26/2022] [Indexed: 06/16/2023]
Abstract
The aim of the present study was to find if workers chronically exposed to lead (Pb) and cadmium (Cd) presented changes in their general health and in the clinical parameters of the population under study. We carried out a cross-sectional survey in a sample of informal workers in Cartagena, Colombia. The population under study was composed of male informal workers (≥18 years of age), with experience in their job, selected from occupational settings with potential exposure to Pb and Cd (i.e., mechanics, battery and garbage recyclers, and welders). The median age was 45 years (interquartile range (IQR), 33−53). The median blood Pb level (BLL) was 2 μg/dL (IQR, 0.76−6.22), and the median of blood Cd level (BCL) was 1.22 μg/L (IQR, 0.33−2.01). The study found that 33% of high exposure jobs with BLL > 5 μg/dL (n = 57), whereas in ‘control’ workers, this was 15.3% (n = 9). The highest BLLs were found in battery recyclers (82.1%; n = 23), followed by mechanics (37.3%, n = 22). In the logistic regression model adjusted by age, time on the job, smoking and elevated BCL and BLL increased 3.2 times (95% CI, 1.1−9.7) in mechanics and 29.6 times (95% CI, 7.2−145.6) in battery recyclers. This study found negative changes in the health of workers with higher chronic exposure to lead in Cartagena, Colombia.
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Affiliation(s)
- Fredy Vergara-Murillo
- Grupo de Química y Medio Ambiente, Facultad de Ciencias Exactas, Universidad de Cartagena, Cartagena 130014, Colombia
| | - Katiana Martinez-Yanez
- Grupo de Química y Medio Ambiente, Facultad de Ciencias Exactas, Universidad de Cartagena, Cartagena 130014, Colombia
| | - Alvaro Fortich-Revollo
- Grupo de Química y Medio Ambiente, Facultad de Ciencias Exactas, Universidad de Cartagena, Cartagena 130014, Colombia
| | | | - Boris Johnson-Restrepo
- Grupo de Química y Medio Ambiente, Facultad de Ciencias Exactas, Universidad de Cartagena, Cartagena 130014, Colombia
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Capitão C, Martins R, Santos O, Bicho M, Szigeti T, Katsonouri A, Bocca B, Ruggieri F, Wasowicz W, Tolonen H, Virgolino A. Exposure to heavy metals and red blood cell parameters in children: A systematic review of observational studies. Front Pediatr 2022; 10:921239. [PMID: 36275050 PMCID: PMC9583003 DOI: 10.3389/fped.2022.921239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mechanistic studies show that heavy metals interfere with the hematopoietic system by inhibiting key enzymes, which could lead to anemia. However, the link between children's exposure and red blood cell (RBC) parameters has been inconsistent. We aimed to summarize evidence on human studies exploring the association between exposure to lead, mercury, cadmium, arsenic, and chromium VI and RBC parameters in children. METHODS Following the PRISMA guidelines, we searched PubMed, Scopus, and Web of Science databases for studies published between January 2010 and April 2022. Eligible papers included human observational studies that directly assessed exposure (internal dose) to the heavy metals under study and RBC parameters in participants aged ≤ 18 years. We excluded studies using hospital-based samples. Study quality was assessed using the National Institutes of Health's Quality Assessment Tools for Cohort and Cross-Sectional Studies. We synthesized the evidence using vote counting based on the direction of the relationship. RESULTS Out of 6,652 retrieved papers, we included a total of 38 (33 assessing lead, four mercury, two cadmium, and two arsenic; chromium VI was not assessed in any included paper). More than half of the studies were conducted in Asia. We found evidence of a positive relationship between lead concentration and hemoglobin (proportion of studies reporting negative relationships = 0.750; 95% Confidence Interval (CI) 0.583, 0.874) and mean corpuscular hemoglobin (0.875; 95% CI 0.546, 0.986), and a positive relationship with red cell distribution width (0.000; 95%CI 0.000, 0.379). When considering only good-quality studies (24% of the Pb studies), only the relationship with hemoglobin levels remained (0.875; 95% CI: 0.546, 0.986). CONCLUSION We found evidence of a negative relationship between lead concentration and hemoglobin and mean corpuscular hemoglobin and of a positive relationship with red cell distribution width in children. We also identified a need to conduct more studies in European countries. Future studies should use standardized practices and make efforts to increase study quality, namely by conducting comprehensive longitudinal studies. Our findings support the need to take further actions to limit heavy metal exposure during childhood.
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Affiliation(s)
- Carolina Capitão
- Environmental Health Behaviour Lab, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Raquel Martins
- Environmental Health Behaviour Lab, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Osvaldo Santos
- Environmental Health Behaviour Lab, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Unbreakable Idea Research, Cadaval, Portugal
| | - Manuel Bicho
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Laboratório de Genética, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Instituto Rocha Cabral, Lisbon, Portugal
| | | | | | - Beatrice Bocca
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - Flavia Ruggieri
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Hanna Tolonen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Ana Virgolino
- Environmental Health Behaviour Lab, Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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