Determinants of Knowledge, Attitudes, Perceptions and Behaviors Regarding Air Pollution in Schoolchildren in Pristina, Kosovo

Air pollution poses a significant public health challenge, and Kosovo, a low-middle-income country in the Balkan peninsula, suffers from particularly poor air quality, especially around the area of the capital Pristina. The availability of accurate and timely information is crucial in mitigating the adverse effects of air pollution. This study aimed at evaluating the knowledge, attitudes, behaviors, and perceptions (KAPB) related to poor air quality in Pristina's low-middle schools. Furthermore, the study explored the connections between these factors and socio-demographic and health attributes and provided valuable inputs for the development of future strategies and policies in air pollution mitigation. Regression analysis provided insights into how these various factors interacted with KAPB scores. The results revealed limited knowledge about air pollution sources and risks among pupils, with insufficient awareness of reliable information sources. While attitudes were generally positive, they declined with higher grade levels. Parental education significantly influenced knowledge and attitudes, and better health correlated with more positive attitudes. Perceptions of air pollution risks were influenced by grade, gender, and parental education, with better-educated parents associated with improved perceptions. Overall behavior scores increased with higher levels of parental education. Understanding the factors that shape pupils' responses to air pollution is critical for strategy and policy development. These findings can guide strategies to enhance environmental awareness and promote healthy behavior, helping address the pressing issue of air pollution in the country.

Time series analysis in environmental epidemiology: challenges and considerations

In environmental epidemiology, time series analyses represent a widely used statistical tool. However, though being commonly used, there is soften confusion regarding the specific requirements, such as which link function might be most appropriate, when or how to control for seasonality or how to account for lags. The present overview draws from experiences in other disciplines and discusses the proper execution of time series analyses based on considerations that are relevant in environmental epidemiology. Time series analysis in environmental epidemiology focuses on acute events caused by short-term changes in exposure. These exposures should be fairly wide-spread affecting a large number of persons, usually all inhabitants of a political entity. Pollutants in air or drinking water as well as meteorological factors serve as typical examples. Despite the many time series analyses performed world-wide, some health effects that would lend themselves to that approach are still under-explored. This would include also some neurological and psychiatric endpoints. Int J Occup Med Environ Health. 2023;36(6):704-16.

Determinants of exposure to acrylamide in European children and adults based on urinary biomarkers: results from the "European Human Biomonitoring Initiative" HBM4EU participating studies

Little is known about exposure determinants of acrylamide (AA), a genotoxic food-processing contaminant, in Europe. We assessed determinants of AA exposure, measured by urinary mercapturic acids of AA (AAMA) and glycidamide (GAMA), its main metabolite, in 3157 children/adolescents and 1297 adults in the European Human Biomonitoring Initiative. Harmonized individual-level questionnaires data and quality assured measurements of AAMA and GAMA (urine collection: 2014-2021), the short-term validated biomarkers of AA exposure, were obtained from four studies (Italy, France, Germany, and Norway) in children/adolescents (age range: 3-18 years) and six studies (Portugal, Spain, France, Germany, Luxembourg, and Iceland) in adults (age range: 20-45 years). Multivariable-adjusted pooled quantile regressions were employed to assess median differences (β coefficients) with 95% confidence intervals (95% CI) in AAMA and GAMA (µg/g creatinine) in relation to exposure determinants. Southern European studies had higher AAMA than Northern studies. In children/adolescents, we observed significant lower AA associated with high socioeconomic status (AAMA:β =  - 9.1 µg/g creatinine, 95% CI - 15.8, - 2.4; GAMA: β =  - 3.4 µg/g creatinine, 95% CI - 4.7, - 2.2), living in rural areas (AAMA:β =  - 4.7 µg/g creatinine, 95% CI - 8.6, - 0.8; GAMA:β =  - 1.1 µg/g creatinine, 95% CI - 1.9, - 0.4) and increasing age (AAMA:β =  - 1.9 µg/g creatinine, 95% CI - 2.4, - 1.4; GAMA:β =  - 0.7 µg/g creatinine, 95% CI - 0.8, - 0.6). In adults, higher AAMA was also associated with high consumption of fried potatoes whereas lower AAMA was associated with higher body-mass-index. Based on this large-scale study, several potential determinants of AA exposure were identified in children/adolescents and adults in European countries.

Prenatal exposure to per- and polyfluoroalkyl substances and pregnancy outcome in Austria

Per- and polyfluoroalkyl substances (PFAS) are a large group of persistent industrial chemicals that can harm reproductive health. PFAS levels were analysed to determine the current sources of exposure and possible associations between prenatal PFAS exposure and adverse pregnancy outcome. Samples from 136 mother-newborn pairs recruited between 2017 and 2019 were analysed for the presence of 31 target PFAS in maternal serum, umbilical cord serum, and placental tissue by high-performance liquid chromatography coupled to a tandem mass spectrometer. Questionnaires and medical records were used to survey sources of exposure and pregnancy outcome, including small for gestational age (SGA), fetal growth restriction (FGR), preeclampsia (PE), preterm birth, large for gestational age (LGA) and gestational diabetes mellitus (GDM). Data were analysed for individual PFAS and sum4PFAS (sum of perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), perfluorohexane sulfonate (PFHxS), and perfluorooctane sulfonate (PFOS) serum levels) in logistic regression analyses and categorical regression analyses. Compared to data from a previous Viennese study in 2010-12, sum4PFAS levels were generally lower. Sum4PFAS serum levels of three women (2.2%) exceeded 6.9 µg/L, a level that corresponds to the recently established tolerable weekly intake (TWI) of EFSA for nursing mothers aged 35 years; in the 2010/2012 study it was 13.6%. The large contribution of unidentified extractable organofluorine (EOF) fractions to total PFAS exposure is a concern. Study site, mean maternal corpuscular hemoglobin (MCH), use of facial lotion, and owning upholstered furniture were significantly influencing maternal exposure. While no effect of sum4PFAS on pregnancy outcome could be detected, we found highest placental PFDA levels in SGA births. PFHxS levels in umbilical cord and placenta were highest in preterm births. Further studies are needed to elucidate the relationship of prenatal PFAS exposure and pregnancy outcome, in particular to confirm whether and how placental PFDA levels may contribute to an increased risk for SGA.

Determinants of COVID-19 Knowledge, Perception and Attitudes in Indonesia: A Cross-Sectional Survey

Many countries, including Indonesia, were gravely affected by the COVID-19 pandemic. While younger people were rarely severely affected by an infection, they still served as important spreaders of the disease. Therefore, the knowledge, perception and attitudes regarding COVID-19 of a mostly younger population was assessed in this study using a quantitative survey and semi-structured questionnaire. Out of 15 questions on COVID-19, males answered fewer questions (-1.26) correctly. Persons reporting more diseases in the last year (+0.49 per disease) that lived in a central area of Indonesia, and that had a better socio-economic status defined through household condition scores, had better knowledge of the symptoms, causes of and measures against COVID-19. Better knowledge independently predicted more responsible attitudes and stated behavior. Knowledge and understanding should be enhanced through information campaigns targeted specifically towards men, persons with poor socio-economic backgrounds and those living in the periphery of the state.

Particulate Air Pollution and Primary Care Visits in Kosovo: A Time-Series Approach

This study aimed to investigate the effects of particulate air pollution (PM2.5) on cardiovascular and respiratory diseases in Pristina, Kosovo, in a time-series analysis using daily primary healthcare visits to primary care institutions from 2019 to 2022. For the observation period, 6440 cardiovascular and 15,141 respiratory visits were reported, whereas the daily mean concentrations of PM2.5 ranged between 2.41 and 120.3 µg/m³. Single-lag models indicated a bi-phasic lag structure with increasing effect estimates some days after the air pollution event. In the distributed lag model with seven lags, the effect estimates for the cardiovascular cases indicated the adverse effect of air pollution. The cumulative effect estimate (summed over lag 0 to 6) for an increase of 10 µg/m³ of PM2.5 was a relative risk of 1.010 (95% confidence interval: 1.001-1.019). For respiratory cases, a different lag model (lag 4 through 10) was additionally examined. In this model, significant increases in visits were observed on lags 7 and 8. Overall, no relevant increase in visits occurred during the seven days considered. Visits to general practitioners will often not occur immediately at disease onset because patients will wait, hoping that their health status improves spontaneously. Therefore, we expected some latency in the effects.

Environmental health, COVID-19, and the syndemic: internal medicine facing the challenge

Internists are experts in complexity, and the COVID-19 pandemic is disclosing complex and unexpected interactions between communicable and non-communicable diseases, environmental factors, and socio-economic disparities. The medicine of complexity cannot be limited to facing comorbidities and to the clinical management of multifaceted diseases. Evidence indicates how climate change, pollution, demographic unbalance, and inequalities can affect the spreading and outcomes of COVID-19 in vulnerable communities. These elements cannot be neglected, and a wide view of public health aspects by a "one-health" approach is strongly and urgently recommended. According to World Health Organization, 35% of infectious diseases involving the lower respiratory tract depend on environmental factors, and infections from SARS-Cov-2 is not an exception. Furthermore, environmental pollution generates a large burden of non-communicable diseases and disabilities, increasing the individual vulnerability to COVID-19 and the chance for the resilience of large communities worldwide. In this field, the awareness of internists must increase, as privileged healthcare providers. They need to gain a comprehensive knowledge of elements characterizing COVID-19 as part of a syndemic. This is the case when pandemic events hit vulnerable populations suffering from the increasing burden of chronic diseases, disabilities, and social and economic inequalities. Mastering the interplay of such events requires a change in overall strategy, to adequately manage not only the SARS-CoV-2 infection but also the growing burden of non-communicable diseases by a "one health" approach. In this context, experts in internal medicine have the knowledge and skills to drive this change.

Time Trends of Acrylamide Exposure in Europe: Combined Analysis of Published Reports and Current HBM4EU Studies

More than 20 years ago, acrylamide was added to the list of potential carcinogens found in many common dietary products and tobacco smoke. Consequently, human biomonitoring studies investigating exposure to acrylamide in the form of adducts in blood and metabolites in urine have been performed to obtain data on the actual burden in different populations of the world and in Europe. Recognizing the related health risk, the European Commission responded with measures to curb the acrylamide content in food products. In 2017, a trans-European human biomonitoring project (HBM4EU) was started with the aim to investigate exposure to several chemicals, including acrylamide. Here we set out to provide a combined analysis of previous and current European acrylamide biomonitoring study results by harmonizing and integrating different data sources, including HBM4EU aligned studies, with the aim to resolve overall and current time trends of acrylamide exposure in Europe. Data from 10 European countries were included in the analysis, comprising more than 5500 individual samples (3214 children and teenagers, 2293 adults). We utilized linear models as well as a non-linear fit and breakpoint analysis to investigate trends in temporal acrylamide exposure as well as descriptive statistics and statistical tests to validate findings. Our results indicate an overall increase in acrylamide exposure between the years 2001 and 2017. Studies with samples collected after 2018 focusing on adults do not indicate increasing exposure but show declining values. Regional differences appear to affect absolute values, but not the overall time-trend of exposure. As benchmark levels for acrylamide content in food have been adopted in Europe in 2018, our results may imply the effects of these measures, but only indicated for adults, as corresponding data are still missing for children.

Air Pollution in Kosovo: Short Term Effects on Hospital Visits of Children Due to Respiratory Health Diagnoses

The Republic of Kosovo is a small country in the Balkans. The capital city of Pristina hosts most of its population and is situated in a mountain basin with poor air exchange, especially during winter. Domestic heating, road transport, industry and coal-fired power plants contribute to high levels of air pollution. We performed a time-series analysis on effects of particulate air pollution (PM2.5) on respiratory health of children and adolescents, using hospital admission and ambulatory visit numbers from the pediatric university clinic. From 2018 until 2020, daily mean concentrations of PM2.5 ranged between 2.41 and 161.03 µg/m³. On average, there were 6.7 ambulatory visits per day with lower numbers on weekends and during the first COVID-19 wave in 2020. An increase in PM2.5 led to an immediate increase in visit numbers that lasted over several days. Averaged over a full week, this amounted to about a 1% increase per 10 µg/m³. There were, on average, 1.7 hospital admissions per day. Two and three days after a rise in air pollution, there was also a rise in admission numbers, followed by a decline during the consecutive days. This might indicate that the wards were overstressed because of high admission numbers and restricted additional admissions.

Temporal patterns of weekly births and conceptions predicted by meteorology, seasonal variation, and lunar phases

Background

Data reporting the number of births given by women resident in Vienna for each week between 1999 and 2019, and the duration (in weeks) of their pregnancies, were used to estimate the week of conception. When preliminary examinations detected cyclical patterns for births and conceptions, a series of Poisson regressions for births and conceptions were performed to assess whether these cycles could be associated with lunar or solar phases.

Methods

To that end 2 sine-cosine functions, 1 with a wavelength of 1 year (365.25 days) and 1 with a wavelength of 29.529 days, the latter resembling the average length of a lunar cycle, were constructed. In addition, also average weekly temperatures were included in the models.

Results

Same week temperature was a strong non-linear predictor for both births and conceptions. Extreme temperatures, especially hot temperatures, increased the number of births while the numbers of successful conceptions were decreased by extreme temperatures. Regarding annual variation in conceptions, the lowest values were found in May and the highest in late autumn and early winter. Therefore, the highest numbers of births are observed in the summer. As per lunar variations, the highest numbers of conceptions occurred at the full moon and the highest numbers of births at the waxing crescent to first quarter moon.

Discussion

The latter results should be treated with caution, as they are not hypothesis driven. Furthermore, literature reports on this topic are conflicting. Nevertheless, these findings will be useful in further analyses examining air pollution effects.

The questionnaire design process in the European Human Biomonitoring Initiative (HBM4EU)

BACKGROUND

Designing questionnaires is a key point of epidemiological studies assessing human exposure to chemicals. The lack of validated questionnaires can lead to the use of previously developed and sub-optimally adapted questionnaires, which may result in information biases that affect the study's validity. On this ground, a multidisciplinary group of researchers developed a series of tools to support data collection within the HBM4EU initiative. The objective of this paper is to share the process of developing HBM4EU questionnaires, as well as to provide researchers with harmonized procedures that could help them to design future questionnaires to assess environmental exposures.

METHODS

In the frame of the work package on survey design and fieldwork of the HBM4EU, researchers carried out procedures necessary for the development of quality questionnaires and related data collection tools. These procedures consisted of a systematic search to identify questionnaires used in previous human biomonitoring (HBM) studies, as well as the development of a checklist and evaluation sheet to assess the questionnaires identified. The results of these evaluations were taken into consideration for the development of the final questionnaires.

RESULTS

The main points covered by each of the sections included in HBM4EU questionnaires are described and discussed in detail. Additional tools developed for data collection in the HBM4EU (e.g. non-responder questionnaire, satisfaction questionnaire, matrix-specific questionnaire) are also addressed. Special attention is paid to the limitations faced and hurdles overcome during the process of questionnaire development.

CONCLUSIONS

Designing questionnaires for use in HBM studies requires substantial effort by a multidisciplinary team to guarantee that the quality of the information collected meets the study's objectives. The process of questionnaire development described herein will contribute to improve the harmonization of HBM studies within the social and environmental context of the EU countries.

Perfluorooctane sulfonic acid (PFOS) inhibits vessel formation in a human 3D co-culture angiogenesis model (NCFs/HUVECs)

Perfluorooctane sulfonic acid (PFOS) is a ubiquitous environmental pollutant. In humans, PFOS exposure has been associated with a number of adverse health outcomes, including reduced birth weight. Whether PFOS is capable of affecting angiogenesis and thus possibly fetal development is unknown. Therefore, we investigated 1) the metabolic activity of PFOS-exposed endothelial cells (human umbilical vein endothelial cells, HUVECs), fibroblasts (normal colon fibroblasts, NCFs), and epithelial cells (human colorectal carcinoma cells, HCT116), 2) PFOS-specific inhibition of vascular endothelial growth factor receptor (VEGFR)2 stimulation in KDR/NFAT-RE HEK293 cells, and 3) the antiangiogenic potential of PFOS in a 3D in vitro angiogenesis model of HUVECs and NCFs. In terms of metabolic activity, endothelial cells (HUVECs) were much more sensitive to PFOS than fibroblasts (NCFs) or epithelial cells (HCT116). VEGFR2 signaling in KDR/NFAT-RE HEK293 cells decreased with increasing PFOS concentrations. In co-culture (angiogenesis assay), PFOS treatment resulted in a dose-dependent reduction in tip and branch formation, tip length (μm), and total structural area (μm²) with stable metabolic activity of HUVECs up to high concentrations. We conclude that PFOS possesses antiangiogenic properties. Inhibition of VEGFR2 signaling indicates a possible mechanism of action that can be linked to an existing Adverse Outcome Pathway (AOP43) containing the AO reduced birth weight. Further studies are needed to confirm PFOS-specific adverse effects on angiogenesis, placental perfusion, and fetal growth.

The Critical Importance of Molecular Biomarkers and Imaging in the Study of Electrohypersensitivity. A Scientific Consensus International Report

Clinical research aiming at objectively identifying and characterizing diseases via clinical observations and biological and radiological findings is a critical initial research step when establishing objective diagnostic criteria and treatments. Failure to first define such diagnostic criteria may lead research on pathogenesis and etiology to serious confounding biases and erroneous medical interpretations. This is particularly the case for electrohypersensitivity (EHS) and more particularly for the so-called "provocation tests", which do not investigate the causal origin of EHS but rather the EHS-associated particular environmental intolerance state with hypersensitivity to man-made electromagnetic fields (EMF). However, because those tests depend on multiple EMF-associated physical and biological parameters and have been conducted in patients without having first defined EHS objectively and/or endpoints adequately, they cannot presently be considered to be valid pathogenesis research methodologies. Consequently, the negative results obtained by these tests do not preclude a role of EMF exposure as a symptomatic trigger in EHS patients. Moreover, there is no proof that EHS symptoms or EHS itself are caused by psychosomatic or nocebo effects. This international consensus report pleads for the acknowledgement of EHS as a distinct neuropathological disorder and for its inclusion in the WHO International Classification of Diseases.

Health Symptoms Related to Pesticide Use in Farmers and Laborers of Ecological and Conventional Banana Plantations in Ecuador

Conventional banana farming is pesticide-intensive and leads to high exposure of farmworkers. Ecuador is the world’s biggest exporter of bananas. In this field study in 5 communities in Ecuador, we recorded potentially pesticide-associated subjective health symptoms in farmworkers and compared pesticide users to workers in organic farming. With one exception, symptom rates were always higher in the pesticide-exposed group. Significance was reached in 8 out of 19 investigated symptoms with the highest odds ratios (and smallest p-values) for local irritation like skin and eye irritation (OR = 3.58, CI 1.10–11.71, and 4.10, CI 1.37–12.31, respectively) as well as systemic symptoms like dizziness (OR = 4.80, CI 1.55–14.87) and fatigue (OR = 4.96, CI 1.65–14.88). Moreover, gastrointestinal symptoms were reported more frequently by pesticide users: nausea (OR = 7.5, CI 1.77–31.77) and diarrhea (OR = 6.43, CI 1.06–30.00). The majority of farmworkers were not adequately protected from pesticide exposure. For example, only 3 of 31 farmworkers that had used pesticides recently reported using gloves and only 6 reported using masks during active spraying. Improved safety measures and a reduction in pesticide use are necessary to protect the health of banana farmworkers.

Air Pollution Is Associated with COVID-19 Incidence and Mortality in Vienna, Austria

We determined the impact of air pollution on COVID-19-related mortality and reported-case incidence, analyzing the correlation of infection case numbers and outcomes with previous-year air pollution data from the populations of 23 Viennese districts. Time at risk started in a district when the first COVID-19 case was diagnosed. High exposure levels were defined as living in a district with an average (year 2019) concentration of nitrogen dioxide (NO2) and/or particulate matter (PM10) higher than the upper quartile (30 and 20 µg/m3, respectively) of all districts. The total population of the individual districts was followed until diagnosis of or death from COVID-19, or until 21 April 2020, whichever came first. Cox proportional hazard regression was performed after controlling for percentage of population aged 65 and more, percentage of foreigners and of persons with a university degree, unemployment rate, and population density. PM10 and NO2 were significantly and positively associated with the risk of a COVID-19 diagnosis (hazard ratio (HR) = 1.44 and 1.16, respectively). NO2 was also significantly associated with death from COVID-19 (HR = 1.72). Even within a single city, higher levels of air pollution are associated with an adverse impact on COVID-19 risk.

Impact of air pollution on symptom severity during the birch, grass and ragweed pollen period in Vienna, Austria: Importance of O3 in 2010-2018

Air pollution is a threat to the general population, especially to pollen allergy sufferers in urban environments. Different air quality parameters have hitherto been examined which add to the burden of pollen allergy sufferers. Parameters such as NO₂, SO₂, PM₁₀, PM_2.5, and O₃ are supposed to have additional impact, not only on health in general (increase in asthma, allergy sensitization frequency), but also on pollen grains (increase of allergenicity). However, it remains unknown if those air quality parameters increase symptom severity during the pollen season. We selected the birch, grass, and ragweed pollen seasons as different time periods throughout the year and analyzed the relationship of symptom data to pollen, air quality, and meteorological data (temperature, relative humidity) for the metropolis of Vienna (Austria). A linear regression model was computed based on different symptom data, and both pollen and air quality data were tested simultaneously. Ozone was positively and significantly associated with symptom scores in all three seasons, whereas this was only rarely the case with other pollutants. Therefore, only ozone was selected for further analysis in a model including meteorological parameters. In this model, effect estimates of ozone were attenuated but remained significant for the grass pollen season. The lack of significance in the other seasons may be attributed to the less numerous symptom data entries and the shorter duration of the pollen seasons for birch and ragweed. All other air quality parameters usually showed lower concentrations during the pollen seasons and displayed little variation. This might explain the lack of a clear signal. Our results suggest that today's allergic population is already affected by air quality (rising O₃ levels). Air quality should be considered as well in pollen information and pollen allergy studies in general because of its increasing importance in the light of global warming.

Nitrogen-Dioxide Remains a Valid Air Quality Indicator

In epidemiological studies, both spatial and temporal variations in nitrogen dioxide (NO₂) are a robust predictor of health risks. Compared to particulate matter, the experimental evidence for harmful effects at typical ambient concentrations is less extensive and not as clear for NO₂. In the wake of the “Diesel emission scandal—Dieselgate”, the scientific basis of current limit values for ambient NO₂ concentrations was attacked by industry lobbyists. It was argued that associations between NO₂ levels and medical endpoints were not causal, as NO₂ in older studies served as a proxy for aggressive particulate matter from incineration processes. With the introduction of particle filters in diesel cars, NO₂ would have lost its meaning as a health indicator. Austria has a high percentage of diesel-powered cars (56%). If, indeed, associations between NO₂ concentrations and health risks in previous studies were only due to older engines without a particle filter, we should expect a reduction in effect estimates over time as an increasing number of diesel cars on the roads were outfitted with particle filters. In previous time series studies from Vienna over shorter time intervals, we have demonstrated distributed lag effects over days up to two weeks and previous day effects of NO₂ on total mortality. In a simplified model, we now assess the effect estimates for moving 5-year periods from the beginning of NO₂ monitoring in Vienna (1987) until the year 2018 of same and previous day NO₂ on total daily mortality. Contrary to industry claims of a spurious, no longer valid indicator function of NO₂, effect estimates remained fairly stable, indicating an increase in total mortality of previous day NO₂ by 0.52% (95% CI: 0.35–0.7%) per 10 µg/m³ change in NO₂ concentration.

Validity of reported indicators of pesticide exposure and relevance for cytotoxic and genotoxic effects on buccal cells

Higher rates of nuclear anomalies in buccal cells of coffee workers exposed to pesticides in comparison to their unexposed peers were detected in our field study. Here, we extend our findings by examining other exposure indicators in this sample. Occupational exposure of 38 exposed and 33 non-exposed farmworkers was assessed as exposure days in the last month (0-25 days) and as years of exposure (0-47 years). Genotoxic and cytotoxic markers in buccal cells were analysed following standard procedures for buccal micronucleus cytome assay. Both exposure markers were associated with a higher frequency of nuclear anomalies with odds ratios more than 1. After restricting the analysis to the exposed workers only, this association remained only with the marker of recent exposure. In a secondary analysis also environmental exposure defined as proximity of the home to the nearest sprayed field (distance <1000 m) was assessed. Proximity led to increased rates (with odds ratios more than 3) of genotoxic but not cytotoxic nuclear anomalies. Reported recent frequency and intensity of pesticide use and application are a valid exposure marker relevant for cytological pathologies in the buccal mucosa. The exposure metric for environmental exposure was rather crude and confounding by some unmeasured factor cannot be fully excluded. Nevertheless, simple exposure indicators that can even be obtained under rather difficult field conditions do provide health-relevant and valid information.

Time Course of COVID-19 Cases in Austria

COVID-19 is an infectious disease caused by a novel coronavirus, which first appeared in China in late 2019, and reached pandemic distribution in early 2020. The first major outbreak in Europe occurred in Northern Italy where it spread to neighboring countries, notably to Austria, where skiing resorts served as a main transmission hub. Soon, the Austrian government introduced strict measures to curb the spread of the virus. Using publicly available data, we assessed the efficiency of the governmental measures. We assumed an average incubation period of one week and an average duration of infectivity of 10 days. One week after the introduction of strict measures, the increase in daily new cases was reversed, and the reproduction number dropped. The crude estimates tended to overestimate the reproduction rate in the early phase. Publicly available data provide a first estimate about the effectiveness of public health measures. However, more data are needed for an unbiased assessment.

Daylight Saving Time Transitions: Impact on Total Mortality

In Europe and many countries worldwide, a half-yearly changing time scheme has been adopted with the aim of optimizing the use of natural daylight during working hours and saving energy. Because the expected net economic benefit was not achieved, the discussion about the optimal solution has been reopened with a shifted focus on social and health related consequences. We set out to produce evidence for this discussion and analysed the impact of daylight saving time on total mortality of a general population in a time series study on daily total mortality for the years 1970–2018 in the city of Vienna, Austria. Daily deaths were modelled by Poisson regression controlling for seasonal and long-term trend, same-day and 14-day average temperature, humidity, and day of week. During the week after the spring transition a significant increase in daily total mortality of about 3% per day was observed. This was not the case during the week after the fall transition. The increase in daily mortality as observed in the week after spring DST-transition is most likely causally linked to the change in time scheme.

Indicators of Genotoxicity in Farmers and Laborers of Ecological and Conventional Banana Plantations in Ecuador

Banana farming represents an important segment of agricultural production in Ecuador. The health of farmworkers might be compromised by the extensive use of pesticides in plantations applied under poorly regulated conditions. Due to an increased awareness of pesticide-related problems for nature, as well as for worker and consumer health, ecological farming has been established in some plantations of Ecuador. We set out to investigate the occupational health of workers in both conventional and ecological farming. Nuclear anomalies in buccal epithelial cells were used as short-term indicators for genotoxicity and a potentially increased cancer risk in the two groups of farmworkers. By application of the Buccal Micronucleus Cytome Assay (BMCA), we found the frequency of micronuclei in conventional pesticide using farmworkers significantly increased by 2.6-fold, and other nuclear anomalies significantly increased by 24% to 80% (except pyknosis with a non-significant increase of 11%) compared to the farmworkers on ecological plantations. These results demonstrate that ecological farming may provide an alternative to extensive pesticide use with significantly reduced indicators of cancer risk. In conventional farming, improvements in education and instruction regarding the safe handling of pesticides and protective equipment, as well as regulatory measures, are urgently needed.

Iron and Iodine Status in Pregnant Women from A Developing Country and Its Relation to Pregnancy Outcomes

Birth related complications and comorbidities are highly associated with a poor nutritional status of pregnant women, whereas iron and iodine are among especially important trace elements for healthy maternal and fetal outcomes. The study compares the status of iron, iodine, and related functional parameters in pregnant and non-pregnant women from a developing country and associates the data with pregnancy complications. The concentrations of ferritin, hemoglobin (Hb), total triiodothyronine (TT3), total thyroxine (TT4), and thyroid-stimulating hormone (TSH) were determined in the blood serum of 80 pregnant women at the time of delivery and compared with 40 non-pregnant healthy controls. Spot urine samples were taken to evaluate the urinary iodine concentration (UIC). In pregnant women, ferritin, Hb concentrations, and UIC were significantly lower, and TT4 values were significantly higher compared to controls. Higher Hb levels were tendentially associated with a reduced risk for pregnancy complications (OR = 0.747, CI (95%) 0.556–1.004; p = 0.053). Regarding covariates, only previous miscarriages were marginally associated with pregnancy complications. High consumption of dairy products was associated with lower Hb and ferritin values. Our results suggest that pregnant women from a developing country have lower iron status with Hb levels being possibly associated with pregnancy complications.

Evaluating an 80 Hz tonal noise from a hydropower plant

A pumped storage power plant produces significant noise such that adjacent areas were deemed uninhabitable for the local population. In recent years, the population in the area has increased, and the noise levels are now causing significant distress to the local population. The company operating the power plant and a citizens' initiative have both commissioned noise measurements. The measurements showed that the continuous pump noise was audible over many kilometers. The A-weighted sound-pressure level of 50 dBA at the next residential area underestimates the perceived noise, given the clear tonal nature in the low frequency range. Interviews of the exposed population, together with detailed "annoyance diaries" by a sample of the residents, proved their high level of annoyance. Their reported observations on distress and sleep disturbances coincide with the time course of the pumping operation. The pumping noise leads to annoyance in a large area, and to considerable nuisance in a smaller one. For the most exposed homes, long-term exposure might be considered a health hazard due to stress and disturbances in sleep quality. Therefore, the operator committed to developing a technical noise control plan. This case shows that a scientific approach within a complex environmental noise problem can foster an agreement about noise protection measures. However, this can only be successful if all involved parties participate in the process. Pilot studies are underway to test the impact of damping material layers on the pipes, the housing of the pipes, and the kind of air vessel solutions between the pumps and the pipes. Int J Occup Med Environ Health. 2019;32(3):401-11.

Exposure-complaint relationships of various environmental odor sources in Styria, Austria

In the planning and authorization process of industrial plants or agricultural buildings, it needs to be ensured that odor emissions do not annoy nearby residents in an unacceptable way. Previous studies have shown that odor-hour frequency is an important predictor for odor annoyance. However, odor-hour frequencies can be assessed for day and night separately. The present study relates complaint rates with different odor types and different metrics of frequency calculated via a dispersion model. Binary logistic regression analyses show that odor type and frequency of odor-hours are important predictors for complaints, while type of residential area does not increase the predictive value of the model. The combination of calculated frequency of day time odor-hours and type of odor explains complaint rates best. It is recommended to keep odor emissions as low as possible, especially for highly annoying odor types.

Breast-Feeding Protects Children from Adverse Effects of Environmental Tobacco Smoke

In a cross-sectional study on 433 schoolchildren (aged 6⁻9 years) from 9 schools in Austria, we observed associations between housing factors like passive smoking and lung function as well as improved lung function in children who had been breast-fed. The latter findings urged the question of whether the protective effects of breast-feeding act on environmental stressors or if they act independently. Therefore, the effect of passive smoking on lung function was stratified by breast-feeding. The detrimental effects of passive smoking were significant but restricted to the group of 53 children without breast-feeding. Breast-feeding counteracts the effect of environmental stressors on the growing respiratory organs.

Subjective Symptoms of Male Workers Linked to Occupational Pesticide Exposure on Coffee Plantations in the Jarabacoa Region, Dominican Republic

Acute and sub-acute effects of pesticide use in coffee farmers have rarely been investigated. In the present field study, self-reported health symptoms from 38 male pesticide users were compared to those of 33 organic farmers. Results of cytological findings have been reported in an accompanying paper in this issue. The present second part of the study comprises a questionnaire based survey for various, potentially pesticide related symptoms among the coffee farmers. Symptom rates were generally higher in exposed workers, reaching significance in nine out of 19 assessed symptoms. Significantly increased symptom frequencies were related to neurotoxicity, parasympathic effects and acetylcholine esterase inhibition, with the highest differences found for excessive salivation, dizziness and stomach ache. We revealed a lack of precautionary measures in the majority of farmers. Better education, regulations, and safety equipment are urgently needed.

Pesticides Are an Occupational and Public Health Issue

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Prevalence of Second-Hand Smoke Exposure After Introduction of the Italian Smoking Ban: The Florence and Belluno Survey

Aims and Background

A law banning smoking in enclosed public places was implemented in Italy on January 10, 2005. The aim of this paper is to present a cross-sectional survey on two representative samples of non-smokers of two Italian towns (Florence and Belluno), conducted one year after the introduction of the ban, in order to assess prevalence of second-hand smoke exposure, to record the attitudes towards the ban, and the perception about its compliance in a representative sample of non-smokers.

Methods

Computer-assisted telephone interviews were carried out in March 2006, from a random sample of households from telephone registries. Respondents were 402 non-smokers from Belluno and 1,073 from Florence.

Results

About 12% of Florentines and 7% of Belluno respondents were exposed at home; 39% and 19%, respectively, at work; 10% and 5% in hospitality venues; 20% and 10% in cars. The smoke-free law was almost universally supported (about 98%) even if a smaller proportion of people (about 90%) had the perception that the ban was observed.

Conclusions

Second-hand smoke exposure at home and in hospitality premises has dropped to ≤10%, whereas exposure at work remained higher. These results suggest the need for more controls in workplaces other than hospitality venues.

Comment on Zheng et al. Association between Promoter Methylation of Gene ERCC3 and Benzene Hematotoxicity. Int. J. Environ. Res. Public Health 2017, 14, 921

Benzene is an established carcinogenic substance [1,2].[...].

Perinatal health in the Danube region - new birth cohort justified

In 2013-2015, a consortium of European scientists - NEWDANUBE - was established to prepare a birth cohort in the Danube region, including most of the countries with the highest air pollution in Europe, the area being one-fifth of the European Union's (EU's) territory, including 14 countries (nine EU member states), over 100 million inhabitants, with numerous challenges: big socioeconomic disparities, and a region-specific environmental pollution. The consortium reflects the EU Strategy for the Danube Region Strategy (2010), which identified 11 thematic Priority Areas - one of which is the environmental risks. Birth cohorts have been established in all other areas of Europe and collaborative efforts in promoting maternal and fetal health by minimizing the environmental exposures have been initiated with national, European, and international financial support. A birth cohort in the Danube area could apply the established methodologies for prenatal exposure and birth outcome measurements and establish a platform for targeted health promotion in couples planning pregnancies. The consortium included a strong socioeconomic part focusing on the participant's active registration of exposures to environmental toxicants and health indicators of disease and wellbeing, combined with investigation of their risk-reducing behavior and interventions to change their lifestyle to avoid the adverse health risks. Willingness to pay for reducing the health risks in children is also proposed to be estimated. Further collaboration and networking is encouraged as the Danube region has several decades of experience and expertise in biomonitoring adult populations exposed environmentally or occupationally. Additionally, some countries in the Danube region launched small-scale birth cohorts encouraged by participation in several ongoing research projects.

UV-Radiation: From Physics to Impacts

Ultraviolet (UV) radiation has affected life at least since the first life forms moved out of the seas and crawled onto the land. Therefore, one might assume that evolution has adapted to natural UV radiation. However, evolution is mostly concerned with the propagation of the genetic code, not with a long, happy, and fulfilling life. Because rickets is bad for a woman giving birth, the beneficial effects of UV-radiation outweigh the adverse effects like aged skin and skin tumors of various grades of malignancy that usually only afflict us at older age. Anthropogenic damage to the stratospheric ozone layer and frighteningly high rates of melanoma skin cancer in the light-skinned descendants of British settlers in Australia piqued interest in the health impacts of UV radiation. A changing cultural perception of the beauty of tanned versus light skin and commercial interests in selling UV-emitting devices such as tanning booths caught public health experts off-guard. Counseling and health communication are extremely difficult when dealing with a “natural” risk factor, especially when this risk factor cannot (and should not) be completely avoided. How much is too much for whom or for which skin type? How even measure “much”? Is it the (cumulative) dose or the dose rate that matters most? Or should we even construct a more complex metric such as the cumulative dose above a certain dose rate threshold? We find there are still many open questions, and we are glad that this special issue offered us the opportunity to present many interesting aspects of this important topic.

Lung function and dust in climbing halls: two pilot studies

In climbing halls, high levels of dust are found because magnesia powder is used to dry hands. Concerns have been raised about possible health effects after reports from asthmatics experiencing worsening of symptoms while or after climbing. We investigated acute and sub-acute effects of climbing in dusty halls on lung function in two pilot studies. The first study examined 109 climbers before and after a climbing activity that lasted at least 1 h. In the second study, 25 climbers from different age classes participated in a 2-day climbing competition. Of these, 24 agreed to take part in our investigation, but only 22 provided valid lung function tests on both days. The climbers underwent lung function tests before the first round of the competition (in the morning), after the second round approximately 3 h later and in the morning of the second day before the competition started again. In the first study, we found acute effects, a decline in lung function immediately after the exposure, likely due to protective reflexes of the bronchial muscles and stronger declines in persons with higher exhaled nitric oxide (NO) pre-climbing. In the second study, we also expected sub-acute effects on the next day due to inflammation. On the first day of the competition (second study), dust levels at a central monitor increased over time in a linear manner. Most of the dust was in the size range between 2.5 and 10 μm and dust levels of particulate matter (PM10) reached 0.5 mg/m3. There was a decline in lung function over 24 h in persons with higher exhaled NO levels pre-exposure. All spirometric parameters were affected though the effects were not statistically significant in all cases. Younger age classes started earlier in the morning. Because of the increasing trend in dust levels we expected stronger effects with higher numbers but for the acute effects the reverse was true, possibly because younger climbers use magnesia more or with less experience thus causing higher individual exposure. No differences by age or by time of the first climb were observed for the 24-h lung function change.

UV "Indices"-What Do They Indicate?

Ultra-Violet (UV) radiation covers the spectrum of wavelengths from 100 to 400 nm. The potency and biological activity for a variety of endpoints differ by wavelength. For monitoring and communication purposes, different UV action spectra have been developed. These spectra use different weighting functions. The action spectrum for erythemal dose is the most widely used one. This erythemal dose per time or dose-rate has been further simplified into a “UV index”. Following this example, in our review we use the term “index” or (plural) “indices” in a more general description for all simplified single-value measures for any biologically effective UV dose, e.g., for human non-melanoma skin cancer and for previtamin D production rate. Ongoing discussion about the existence of an increased melanoma risk due to UV-A exposure underscores the uncertainties inherent in current weighting functions. Thus, we performed an online literature search to review the data basis for these indices, to understand their relevance for an individual, and to assess the applicability of the indices for a range of exposure scenarios. Even for natural (solar) UV, the spectral composition varies spatially and temporally. Artificial UV sources and personal protection introduce further variation to the spectral composition. Many biological effects are proposed for UV radiation. Only few endpoints have been studied sufficiently to estimate a reliable index. Weighting functions for chronic effects and most importantly for cancer endpoints have been developed in animal models, and often for proxy endpoints only. Epidemiological studies on biological effects of UV radiation should not only depend on single-value weighted UV dose estimates (indexes) but should strive for a more detailed description of the individual exposure. A better understanding of the adverse and beneficial effects of UV radiation by wavelength would also improve medical counseling and health communication regarding individual health-supportive behavior.

Dust and Cobalt Levels in the Austrian Tungsten Industry: Workplace and Human Biomonitoring Data

In general, routine industrial hygiene (IH) data are collected not to serve for scientific research but to check for compliance with occupational limit values. In the preparation of an occupational retrospective cohort study it is vital to test the validity of the exposure assessment based on incomplete (temporal coverage, departments) IH data. Existing IH data from a large hard metal plant was collected. Individual workers’ exposure per year and department was estimated based on linear regression of log-transformed exposure data for dust, tungsten, and cobalt. Estimated data were back-transformed, and for cobalt the validity of the estimates was confirmed by comparison with individual cobalt concentrations in urine. Air monitoring data were available from 1985 to 2012 and urine tests from the years 2008 to 2014. A declining trend and significant differences among departments was evident for all three air pollutants. The estimated time trend fitted the time trend in urine values well. At 1 mg/m³, cobalt in the air leads to an excretion of approximately 200 µg/L cobalt in urine. Cobalt levels in urine were significantly higher in smokers with an interaction effect between smoking and air concentrations. Exposure estimates of individual workers are generally feasible in the examined plant, although some departments are not documented sufficiently enough. Additional information (expert knowledge) is needed to fill these gaps.

EUROPAEM EMF Guideline 2016 for the prevention, diagnosis and treatment of EMF-related health problems and illnesses

Chronic diseases and illnesses associated with non-specific symptoms are on the rise. In addition to chronic stress in social and work environments, physical and chemical exposures at home, at work, and during leisure activities are causal or contributing environmental stressors that deserve attention by the general practitioner as well as by all other members of the health care community. It seems necessary now to take "new exposures" like electromagnetic fields (EMF) into account. Physicians are increasingly confronted with health problems from unidentified causes. Studies, empirical observations, and patient reports clearly indicate interactions between EMF exposure and health problems. Individual susceptibility and environmental factors are frequently neglected. New wireless technologies and applications have been introduced without any certainty about their health effects, raising new challenges for medicine and society. For instance, the issue of so-called non-thermal effects and potential long-term effects of low-dose exposure were scarcely investigated prior to the introduction of these technologies. Common electromagnetic field or EMF sources: Radio-frequency radiation (RF) (3 MHz to 300 GHz) is emitted from radio and TV broadcast antennas, Wi-Fi access points, routers, and clients (e.g. smartphones, tablets), cordless and mobile phones including their base stations, and Bluetooth devices. Extremely low frequency electric (ELF EF) and magnetic fields (ELF MF) (3 Hz to 3 kHz) are emitted from electrical wiring, lamps, and appliances. Very low frequency electric (VLF EF) and magnetic fields (VLF MF) (3 kHz to 3 MHz) are emitted, due to harmonic voltage and current distortions, from electrical wiring, lamps (e.g. compact fluorescent lamps), and electronic devices. On the one hand, there is strong evidence that long-term exposure to certain EMFs is a risk factor for diseases such as certain cancers, Alzheimer's disease, and male infertility. On the other hand, the emerging electromagnetic hypersensitivity (EHS) is more and more recognized by health authorities, disability administrators and case workers, politicians, as well as courts of law. We recommend treating EHS clinically as part of the group of chronic multisystem illnesses (CMI), but still recognizing that the underlying cause remains the environment. In the beginning, EHS symptoms occur only occasionally, but over time they may increase in frequency and severity. Common EHS symptoms include headaches, concentration difficulties, sleep problems, depression, a lack of energy, fatigue, and flu-like symptoms. A comprehensive medical history, which should include all symptoms and their occurrences in spatial and temporal terms and in the context of EMF exposures, is the key to making the diagnosis. The EMF exposure is usually assessed by EMF measurements at home and at work. Certain types of EMF exposure can be assessed by asking about common EMF sources. It is very important to take the individual susceptibility into account. The primary method of treatment should mainly focus on the prevention or reduction of EMF exposure, that is, reducing or eliminating all sources of high EMF exposure at home and at the workplace. The reduction of EMF exposure should also be extended to public spaces such as schools, hospitals, public transport, and libraries to enable persons with EHS an unhindered use (accessibility measure). If a detrimental EMF exposure is reduced sufficiently, the body has a chance to recover and EHS symptoms will be reduced or even disappear. Many examples have shown that such measures can prove effective. To increase the effectiveness of the treatment, the broad range of other environmental factors that contribute to the total body burden should also be addressed. Anything that supports homeostasis will increase a person's resilience against disease and thus against the adverse effects of EMF exposure. There is increasing evidence that EMF exposure has a major impact on the oxidative and nitrosative regulation capacity in affected individuals. This concept also may explain why the level of susceptibility to EMF can change and why the range of symptoms reported in the context of EMF exposures is so large. Based on our current understanding, a treatment approach that minimizes the adverse effects of peroxynitrite - as has been increasingly used in the treatment of multisystem illnesses - works best. This EMF Guideline gives an overview of the current knowledge regarding EMF-related health risks and provides recommendations for the diagnosis, treatment and accessibility measures of EHS to improve and restore individual health outcomes as well as for the development of strategies for prevention.

Newborns health in the Danube Region: Environment, biomonitoring, interventions and economic benefits in a large prospective birth cohort study

BACKGROUND

The EU strategy for the Danube Region addresses numerous challenges including environment, health and socioeconomic disparities. Many old environmental burdens and heavily polluted areas in Europe are located in the Danube Region, consisting of 14 countries, with over 100 million people. Estimating the burden of environmental exposures on early-life health is a growing research area in Europe which has major public health implications, but the data from the Danube Region are largely missing.

AIM

This review presents an inventory of current environmental challenges, related early-life health risks, and knowledge gaps in the Danube Region, based on publicly available databases, registers, and literature, as a rationale and incentive for a new integrated project. The review also proposes the concept for the project aiming to characterize in utero exposures to multiple environmental factors and estimate their effect on early-life health, evaluate economic impact, as well as identify interventions with a potential to harness social norms to reduce emissions, exposures and health risks in the Danube Region.

METHODS

Experts in environmental epidemiology, human biomonitoring and social science in collaboration with clinicians propose to establish a new large multi-center birth cohort of mother-child pairs from Danube countries, measure biomarkers of exposure and health in biological samples at birth, collect centrally measured climate, air and water pollution data, conduct pre- and postnatal surveys on lifestyle, indoor exposures, noise, occupation, socio-economic status, risk-averting behavior, and preferences; and undertake clinical examinations of children at and after birth. Birth cohort will include at least 2000 newborns per site, and a subset of at least 200 mother-child pairs per site for biomonitoring. Novel biomarkers of exposure, susceptibility, and effect will be applied, to gain better mechanistic insight. Effects of multiple environmental exposures on fetal and child growth, respiratory, allergic, immunologic, and neurodevelopmental health outcomes will be estimated. Parent's willingness to pay for reducing health risks in children will be elicited by survey, while values of cost-of-illness will be gathered from literature and national statistics. Effects of risk reducing interventions will be examined.

CONCLUSIONS

The proposed project would provide novel estimates of the burden of early childhood diseases attributable to environmental exposures and assess health impacts of different intervention scenarios in the Danube Region, in an integrated approach combining human biomonitoring, epidemiological and social science research.

Sunbed Use Prevalence and Associated Skin Health Habits: Results of a Representative, Population-Based Survey among Austrian Residents

Recreational sunbed use accounts for the main non-solar source of exposure to ultraviolet radiation in fair-skinned Western populations. Indoor tanning is associated with increased risks for acute and chronic dermatological diseases. The current community-based study assessed the one-year prevalence of sunbed use and associated skin health habits among a representative, gender-balanced sample of 1500 Austrian citizens. Overall one-year prevalence of sunbed use was 8.9% (95% confidence interval (CI) 7.5%-10.4%), with slightly higher prevalence in females (9.2%, 95% CI 7.3%-11.2%) compared to males (8.6%, 95% CI 6.7%-10.6%). Factors predicting sunbed use were younger age (by trend decreasing with older age), place of living, smoking, skin type (by trend increasing with darker skin), sun exposure, motives to tan, and use of UV-free tanning products. Despite media campaigns on the harmful effects of excessive sunlight and sunbed exposure, we found a high prevalence of self-reported sunbed use among Austrian citizens. From a Public (Skin) Health perspective, the current research extends the understanding of prevailing leisure time skin health habits in adding data on prevalence of sunbed use in the general Austrian population.

Sun Exposure Prevalence and Associated Skin Health Habits: Results from the Austrian Population-Based UVSkinRisk Survey

Recreational sun exposure accounts for a large number of acute and chronic dermatological diseases, including skin cancer. This study aimed at estimating the one-year prevalence of sun exposure and skin health-associated knowledge and attitudes among Austrian citizens. The population-based UVSkinRisk survey investigated a representative sample of Austrian adults using a structured questionnaire. In total, 1500 study subjects (median age 33.0 years, 50.5% females) participated in this questionnaire survey. Among study participants, prevalence of sun exposure was 47%, with slightly higher rates in males (48%) compared to females (46%). Younger age, lower professional category, darker skin type, motives to tan, sunbed use, sunburn, and outdoor sport activity increased the odds for prevalent sun exposure. This is the first population-based study evaluating the prevailing sun exposure and recreational habits influencing skin health among Austrian citizens. Despite public media campaigns educating on the harmful effects of sunlight exposure, we found a high prevalence of self-reported sunlight exposure. The results suggest that multifaceted socio-cultural characteristics stimulate recreational sun exposure and tanning habits. Communicating individualized Public (Skin) Health messages might be the key to prevent photo-induced skin health hazards in light-skinned populations. The practical and theoretical implications of these findings are discussed.

Health impacts of anthropogenic biomass burning in the developed world

Climate change policies have stimulated a shift towards renewable energy sources such as biomass. The economic crisis of 2008 has also increased the practice of household biomass burning as it is often cheaper than using oil, gas or electricity for heating. As a result, household biomass combustion is becoming an important source of air pollutants in the European Union.This position paper discusses the contribution of biomass combustion to pollution levels in Europe, and the emerging evidence on the adverse health effects of biomass combustion products.Epidemiological studies in the developed world have documented associations between indoor and outdoor exposure to biomass combustion products and a range of adverse health effects. A conservative estimate of the current contribution of biomass smoke to premature mortality in Europe amounts to at least 40 000 deaths per year.We conclude that emissions from current biomass combustion products negatively affect respiratory and, possibly, cardiovascular health in Europe. Biomass combustion emissions, in contrast to emissions from most other sources of air pollution, are increasing. More needs to be done to further document the health effects of biomass combustion in Europe, and to reduce emissions of harmful biomass combustion products to protect public health.

Gender aspects of recreational sun-protective behavior: results of a representative, population-based survey among Austrian residents

PURPOSE

Lifetime risk for melanoma skin cancer is enlarged by sunlight exposure and reduced by sun protection. Austrian melanoma incidence and mortality rates are constantly rising with higher rates in males. Thus, we aimed at investigating gender-specific recreational sun exposure habits among the Austrian population.

METHODS

We conducted a telephone survey among 1500 adults (50.5% females) representing sociodemographic characteristics of the Austrian population. Using a structured questionnaire, we studied gender-specific sun exposure-related knowledge, motives to tan, and behavior.

RESULTS

Overall, using sunscreen, wearing sunglasses, and seeking shade were among the three most frequent sun safe measures. Basic skin health knowledge and tanning motives were similar among genders, although females protected themselves more. In general, sunburn occurrence (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.0-1.8), skin type IV (OR = 2.4, 95% CI = 1.3-4.5), ex-/non-smoking (OR = 1.4-1.6, 95% CI = 1.0-2.1), low motives to tan (both OR = 1.3, 95% CI = 1.0-1.7), no outdoor sport (OR = 1.3, 95% CI = 1.0-1.7), all P < 0.05, as well as the use of sunscreen with lower SPF values (OR = 1.0-3.0, 95% CI = 1.4-4.3) and male gender (OR = 1.6, 95% CI = 1.2-2.0), both P < 0.001, increased the odds of practicing low sun protection.

CONCLUSION

The results of this investigation suggest considering gender specificity when planning Public (Skin) Health-related educative campaigns and programs, for example, by highlighting the appearance-related benefits of sun light avoidance.

Perceived Relevance of Educative Information on Public (Skin) Health: Results of a Representative, Population-Based Telephone Survey

Individual skin health attitudes are influenced by various factors, including public education campaigns, mass media, family, and friends. Evidence-based, educative information materials assist communication and decision-making in doctor-patient interactions. The present study aims at assessing the prevailing use of skin health information material and sources and their impact on skin health knowledge, motives to tan, and sun protection. We conducted a questionnaire survey among a representative sample of Austrian residents. Print media and television were perceived as the two most relevant sources for skin health information, whereas the source physician was ranked third. Picking the information source physician increased participants' skin health knowledge (p = 0.025) and sun-protective behavior (p < 0.001). The study results highlight the demand for targeted health messages to attain lifestyle changes towards photo-protective habits. Providing resources that encourage pro-active counseling in every-day doctor-patient communication could increase skin health knowledge and sun-protective behavior, and thus, curb the rise in skin cancer incidence rates.

Health impacts of anthropogenic biomass burning in the developed world

Climate change policies have stimulated a shift towards renewable energy sources such as biomass. The economic crisis of 2008 has also increased the practice of household biomass burning as it is often cheaper than using oil, gas or electricity for heating. As a result, household biomass combustion is becoming an important source of air pollutants in the European Union.This position paper discusses the contribution of biomass combustion to pollution levels in Europe, and the emerging evidence on the adverse health effects of biomass combustion products.Epidemiological studies in the developed world have documented associations between indoor and outdoor exposure to biomass combustion products and a range of adverse health effects. A conservative estimate of the current contribution of biomass smoke to premature mortality in Europe amounts to at least 40 000 deaths per year.We conclude that emissions from current biomass combustion products negatively affect respiratory and, possibly, cardiovascular health in Europe. Biomass combustion emissions, in contrast to emissions from most other sources of air pollution, are increasing. More needs to be done to further document the health effects of biomass combustion in Europe, and to reduce emissions of harmful biomass combustion products to protect public health.

Diminished pulmonary function in long-term workers exposed to cotton dust determined in a cross-sectional study in small Pakistani enterprises

PURPOSE

While large cotton industry plants producing for the foreign market have undergone improvements of occupational hygiene lately, working conditions in power looms producing mainly for the local market are still poor. The respiratory health in workers of power looms has not been studied so far.

METHODS

In a cross-sectional study, 51 male cotton workers from power looms, 58 from large cotton factories and 52 controls were investigated by spirometry and a symptoms questionnaire. Spirometric measurements and respiratory symptoms were related to exposure duration in large and small factories by multivariate linear regression and logistic regression, respectively, with smoking, age and anthropometric parameters considered as confounders.

RESULTS

Work duration in power looms was associated with declines in forced expiratory volume in 1 s, peak flow, maximum midexpiratory flow and forced expiratory flow 75 and an increased risk of obstruction (OR 1.09/year; 95% CI: 1.002 to 1.18) by applying the Global Lung Initiative equations. Except cough that was only associated with smoking, all respiratory symptoms (chest tightness, shortness of breath, fever) increased as a function of duration of exposure in power looms but not in large factories.

CONCLUSIONS

Despite limitations inherent in the cross-sectional approach, there is evidence for workers in small weaving factories to face an increased risk of pulmonary function loss and respiratory symptoms. Industrial hygiene measures in these small enterprises should be encouraged. Failure to detect adverse respiratory outcomes from occupation in large factories could be due to a 'survivor' (healthy worker) effect.

Replacing fossil diesel by biodiesel fuel: expected impact on health

Biofuels have become an alternative to fossil fuel, but consequences on human health from changes to emissions compositions are not well understood. By combining information on composition of vehicle exhaust, dispersion models, and relationship between exposure to air contaminants and health, the authors determined expected mortality outcomes in 2 scenarios: a blend of 10% biodiesel and 90% standard diesel (B10) and biodiesel only (B100), for a rural and an urban environment. Vehicle exhaust for both fuel compositions contained lower fine particle mass but higher NO2 levels. Ambient air concentrations in scenario B10 were almost unchanged. In scenario B100, PM2.5 (particulate matter with an aerodynamic diameter <2.5 μm) levels decreased by 4-8% and NO2 levels increased 7-11%. Reduction of PM2.5 is expected to reduce mortality rate by 5 × 10(-6) and 31 × 10(-6) per year, whereas NO2 increase adds 17 × 10(-6) and 30 × 10(-6) to mortality rate for B10 and B100, respectively. Since effects of PM2.5 and NO2 are not independent, a positive net effect is possible.

EUROPAEM EMF Guideline 2015 for the prevention, diagnosis and treatment of EMF-related health problems and illnesses

Chronic diseases and illnesses associated with unspecific symptoms are on the rise. In addition to chronic stress in social and work environments, physical and chemical exposures at home, at work, and during leisure activities are causal or contributing environmental stressors that deserve attention by the general practitioner as well as by all other members of the health care community. It seems certainly necessary now to take "new exposures" like electromagnetic field (EMF) into account. Physicians are increasingly confronted with health problems from unidentified causes. Studies, empirical observations, and patient reports clearly indicate interactions between EMF exposure and health problems. Individual susceptibility and environmental factors are frequently neglected. New wireless technologies and applications have been introduced without any certainty about their health effects, raising new challenges for medicine and society. For instance, the issue of so-called non-thermal effects and potential long-term effects of low-dose exposure were scarcely investigated prior to the introduction of these technologies. Common EMF sources include Wi-Fi access points, routers and clients, cordless and mobile phones including their base stations, Bluetooth devices, ELF magnetic fields from net currents, ELF electric fields from electric lamps and wiring close to the bed and office desk. On the one hand, there is strong evidence that long-term-exposure to certain EMF exposures is a risk factor for diseases such as certain cancers, Alzheimer's disease and male infertility. On the other hand, the emerging electromagnetic hypersensitivity (EHS) is more and more recognized by health authorities, disability administrators and case workers, politicians, as well as courts of law. We recommend treating EHS clinically as part of the group of chronic multisystem illnesses (CMI) leading to a functional impairment (EHS), but still recognizing that the underlying cause remains the environment. In the beginning, EHS symptoms often occur only occasionally, but over time they may increase in frequency and severity. Common EHS symptoms include headaches, concentration difficulties, sleeping problems, depression, lack of energy, fatigue and flu-like symptoms. A comprehensive medical history, which should include all symptoms and their occurrences in spatial and temporal terms and in the context of EMF exposures, is the key to the diagnosis. The EMF exposure can be assessed by asking for typical sources like Wi-Fi access points, routers and clients, cordless and mobile phones and measurements at home and at work. It is very important to take the individual susceptibility into account. The primary method of treatment should mainly focus on the prevention or reduction of EMF exposure, that is, reducing or eliminating all sources of EMF at home and in the workplace. The reduction of EMF exposure should also be extended to public spaces such as schools, hospitals, public transport, and libraries to enable persons with EHS an unhindered use (accessibility measure). If a detrimental EMF exposure is reduced sufficiently, the body has a chance to recover and EHS symptoms will be reduced or even disappear. Many examples have shown that such measures can prove effective. Also the survival rate of children with leukemia depends on ELF magnetic field exposure at home. To increase the effectiveness of the treatment, the broad range of other environmental factors that contribute to the total body burden should also be addressed. Anything that supports a balanced homeostasis will increase a person's resilience against disease and thus against the adverse effects of EMF exposure. There is increasing evidence that EMF exposure has a major impact on the oxidative and nitrosative regulation capacity in affected individuals. This concept also may explain why the level of susceptibility to EMF can change and why the number of symptoms reported in the context of EMF exposures is so large. Based on our current understanding, a treatment approach that minimizes the adverse effects of peroxynitrite - as has been increasingly used in the treatment of multisystem disorders - works best. This EMF Guideline gives an overview of the current knowledge regarding EMF-related health risks and provides concepts for the diagnosis and treatment and accessibility measures of EHS to improve and restore individual health outcomes as well as for the development of strategies for prevention.